Inspection on 05/10/06 for 523 - 525 Marfleet Lane

This inspection was carried out on 5th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

523 - 525 Marfleet Lane 02/10/08

523 - 525 Marfleet Lane 13/12/05

523 - 525 Marfleet Lane 04/07/05

523 - 525 Marfleet Lane 17/03/05

523 - 525 Marfleet Lane 17/11/04

523 - 525 Marfleet Lane 04/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 523 - 525 Marfleet Lane 523 525 Marfleet Lane Hull East Yorkshire HU9 4EP Lead Inspector Christina Bettison Key Unannounced Inspection 5th October 2006 09:30 DS0000000915.V309536.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 DS0000000915.V309536.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. DS0000000915.V309536.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 523 - 525 Marfleet Lane Address 523 525 Marfleet Lane Hull East Yorkshire HU9 4EP 01482 796093 01482 329337 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) Avocet Trust Position Vacant Care Home 7 Category(ies) of Learning disability (7) registration, with number of places DS0000000915.V309536.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 2005 Brief Description of the Service: The service at 523-525 Marfleet Lane is managed by Avocet Trust who rent the premises from Sanctuary Housing. It is one of a small number of similar services that Avocet provides. Avocet Trust is a registered charity. 523-525 Marfleet Lane consists of two units registered to provide personal care and accommodation for up to 7 adults of either gender with a learning disability. The home is purpose built, designed to meet the needs of the service users who live there and is situated to the east of the city centre. The accommodation consists of seven single rooms (four in one unit and three in the other) and each unit has its own kitchen, laundry, and bathing facilities. All accommodation is on the ground floor with wheelchair access. There are gardens to the rear of each unit and some parking space to the front of the home. The home is on a main bus route into the city centre and close by are shops, pubs, GP surgeries and leisure / recreational facilities. Weekly fees range from £249.40 to £377.90 per person per week. Additional charges are made for the following: newspapers/magazines, hairdressing, chiropody, transport for social activities and sweets. Information on the service is made available to current service users via the statement of purpose, service user guide and inspection report. DS0000000915.V309536.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection (although the inspector told the Manager a day before that she would be coming on this day to make sure that staff and service users would be in) and took place over 1 day in October 2006. 2 Relative’s questionnaires were returned; 3 service user questionnaires were returned, 1 GP questionnaire was returned and 5 staff questionnaires were returned. During the visit the inspector spoke to the Manager, 2 social workers in training on placement at the home, several staff and a relative, to find out how the home was run and if the people who lived there were getting appropriate care. The service users that live at Marfleet Lane have complicated needs and are not able to tell the inspector of their views so in this report comments from relatives and social workers have been used to help to see whether service users needs are met or not. The inspector watched the way staff behaved with service users to see if service user were satisfied or not. The inspector looked around the home and looked at the records. Before the visit the inspector looked at information sent to the Commission for Social Care Inspection. The site visit was led by Regulation Inspector Mrs. C. Bettison and the visit lasted seven hours. Two social workers in training who were on placement at the home were spoken to as part of the inspection, they both commented that the staff promote dignity and respect for service users, that they are very caring and relaxed with service users and this in turn created an easy going rapport in the house. They stated that service user were very settled and content. They also commented they had been well supported in their learning and development whilst at the home. What the service does well: Avocet Trust provides accommodation and personal care support and is a good service for adults with a learning disability and other needs. Their main aim is to enable people to develop as much independence as possible, whilst helping them to be more confident and access community facilities. DS0000000915.V309536.R01.S.doc Version 5.2 Page 6 Service users and their relatives/advocates are given enough information about the home to help them to make a choice about whether the home will suit them or not. Each service user is assessed by a professional person and they have an individual plan that helps the staff to know what help they need and makes sure that their needs are met. Service users are helped to go out into the community and enjoy a range of leisure activities and holidays that meet their individual needs. Service users receive a healthy diet and their likes and dislikes are also taken into account. Families are made to feel welcome when visiting their relative. The home have a complaints procedure that is understood and used and staff know what to do to make sure service users are protected from harm. All service users live in a home that it is safe and comfortable and are provided with a single room that is nicely personalised to their own taste, in a house for no more than 5 people thereby providing them private space to their liking where they can spend private time or receive visitors. When new staff are given a job with Avocet they have all the necessary checks done to make sure they are suitable people to work with the people living at the home and keep them safe. Avocet Trust have a range of policies and procedures (rules) that are up to date and staff know what to do to make sure service users needs are met. What has improved since the last inspection? A training audit has been developed and all staff have had an individual appraisal to identify what training they need so that the manager can develop a training plan. The new staff have almost finished the LDAF induction, this means that they have a better understanding of their job and the needs of the people living at the home. All of the staff have completed the medication training. The rules for staff when service users are assisted to eat by the use of a Percutaneous Endoscopic Gastrostomy have been amended so that the staff have clear guidance. DS0000000915.V309536.R01.S.doc Version 5.2 Page 7 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. DS0000000915.V309536.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 DS0000000915.V309536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Service users and their relatives and/or advocates are given enough information prior to their stay in order for them to make an informed choice and their needs are assessed in full prior to admission ensuring that the staff are able to meet their needs. EVIDENCE: The home has a statement of purpose and a service user guide that has been updated since the previous inspection. Since the previous inspection there had been a planned discharge for a service user to a more appropriate service and two new admissions to this service. The home is now full. Two care files were examined as part of the inspection process, both of these were for recently admitted service users. Both files contained a copy of the care management assessment and care plan and for one of the service users the home had been able to undertake their own assessment. For this service user there was good evidence of a planned transition period including tea time visits and overnight stays. For the other service user due to DS0000000915.V309536.R01.S.doc Version 5.2 Page 10 circumstances outside of the managers’ control it had been an emergency admission. There was evidence that the staff at the home had been enabled to quickly establish the service users needs and provide a service that was appropriate to meet their needs. There was evidence on care files that one of the service users had chosen the paint colours /wallpaper border to decorate their room and he was keen to show the inspector. Evidence from the initial reviews indicated that both service users had settled in to the home very well. DS0000000915.V309536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users needs are met by adequate numbers of staff, the quality of the service user plans and risk assessments are very good, meaning that service users assessed needs are met. EVIDENCE: DS0000000915.V309536.R01.S.doc Version 5.2 Page 12 Two service users care files were examined as part of the inspection process and both contained a copy of the care management assessment and care plan. For one of the service users the manager had also completed an house assessment for the new service user, which covered all the areas identified in 2.3 of this standard. Both service users had an individual plan/IPP that clearly detailed what staff needed to do meet their needs and assist them to retain their independence. The manager confirmed that service users were involved, as far as they were able, in the development and review of their plan and if not relatives and/or advocates assist in this process. Individual plans were reviewed monthly by the key worker and six monthly formal reviews were held with service users, relatives, advocates and other professionals. The individual plans were in written format only but records evidenced that these had been explained to the service user. Comprehensive risk assessments had been completed. For one service user there is a very detailed protocol in place for their particular vulnerability that is understood and followed by all staff. The staff team are very pro active in the protection of this service user from risk of exploitation and/or harm. For another service user there had been a notified incident of choking, following this the risk assessments and individual plan had been amended and there had been no more incidents. Care files contained behaviour management strategies for service users whose behaviour could cause harm to themselves or others and these identified when there was any restriction on choice. There was very good monitoring of incidents and this monitoring evidenced that for both of the recently admitted service users periods of difficult behaviour had reduced following admission, this evidences that service user needs are being met. For one service user who is blind there was evidence on file that they like to wear nail varnish and for their hair to look nice, there was evidence on file that staff ensure that this happens and that staff describe clothes so that the service user can choose which clothes that they wish to wear. Avocet Trust had a policy and procedure for the use of restrictive physical interventions that was detailed and staff had all received training in non-violent crisis intervention. DS0000000915.V309536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. A wide range of activities within the home and community means that service users have the opportunity to participate in stimulating and motivating activities that meet their individual needs, wants and aspirations. EVIDENCE: The manager informed the inspector that none of the service users would be able to have a job however they all participate in community activities. Some service users attended the local authority day services however the inspector was informed that this is due to stop soon as the day services are undergoing a review. The manager and staff will need to ensure that service users are enabled to participate in alternative provision. DS0000000915.V309536.R01.S.doc Version 5.2 Page 14 All service users participated in a range of leisure activities in the community and within the home and some attend Avocets five senses day service. Both service users care files examined contained an activity timetable that included leisure activities such as shopping, watching Hull City AFC, visits to the pub, bowling, swimming, visits to the park, days out, watching videos and TV and listening to music at home. The inspector was informed that none of the service users follow any particular religion or attend any services. All service user have a private bedroom where they can spend private time and they have unrestricted access to all areas of the house. A visiting relative informed the inspector that relatives are made very welcome and are welcome at any reasonable time. The manager and staff promote a healthy eating menu but try to balance this with service users likes/dislikes and special treats on occasions. DS0000000915.V309536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service user’s health, personal and social care needs are being met, however improvement in the management of the medication systems and the development of health action plans would further enhance the service provided. EVIDENCE: DS0000000915.V309536.R01.S.doc Version 5.2 Page 16 The care files for two service users was examined as part of the inspection process and evidenced that service users personal support and healthcare needs had been identified and were being met. Care files contained details of service users visits to hospital and health professionals. This evidenced that service users had regular health check ups with GP, dentist, chiropody, optician, and that they were supported to attend outpatient clinics at the hospital. Referrals to other professionals such as speech and language therapist, and psychologist had been made on behalf of the service users. The inspector was informed that the two new service users have the ongoing support of the community team learning disability professionals. Health Screening had been completed for some service users and referrals had made to the community nurse for Health Action plans to be developed. This would add to the planning and monitoring of service users health needs. Visits from health care professionals could take place in private in the service user’s own bedroom. Care files contained a moving and handling risk assessment if this was appropriate. The home has policies and procedures for the administration of medication and all of the staff have completed the training, however there were some minor errors in the administration of medication. Quantities of medication were not being carried over and where one service users medication had changed the labels and instructions had not been amended. This needs to improve. One of the service users previously living at the home was fed by the use of a Percutaneous Endoscopic Gastrostomy; this had been agreed by the GP, family members and district nurse who retains overall responsibility. The staff had all received training, however at the previous inspection a requirement was made that Avocet must ensure that their Policies and Procedures support this practice and staff had clear unambiguous guidance, this policy and procedure has now been updated and amended. DS0000000915.V309536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has a complaints system that is followed in practice to ensure service users and their relatives views are listened to and acted on. All staff are aware of their responsibilities with respect to POVA and ensure that service user are protected from harm. EVIDENCE: The CSCI had not received any formal complaints about the home since the previous inspection. The home had received one complaint since the previous inspection from a relative, which was followed up promptly and appropriately and has now been resolved. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, restrictive physical interventions and management of service users money and financial affairs. Avocet Trust have developed a pack for The Protection Of Vulnerable Adults (POVA) training, the manager has completed the training and now needs to cascade this to the staff team. However the staff on duty displayed a good understanding of the vulnerable adults procedure and are confident about reporting any concerns and certain that any allegations would be followed up promptly, and the correct action to be taken. DS0000000915.V309536.R01.S.doc Version 5.2 Page 18 The work being undertaken by the staff in the ongoing protection of a service user from exploitation and/or harm and an emergency admission that was expedited in a timely manner to ensure a service user was safe provides evidence that the staff understand the need to protect service users. However the training of all staff must be progressed as soon as possible. DS0000000915.V309536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The environment provides surroundings in which to live. EVIDENCE: service users with comfortable and safe 525 Marfleet Lane The sensory environment/room has been converted into a small office as the inspector was informed that the service users didn’t use the sensory room. It is planned for the hall and bathroom to be decorated soon. 523 Marfleet Lane The hall and utility room were in the process of being decorated. The bathrooms in both houses appear clinical and institutional and require updating. The kitchens on both houses are in need of refurbishment as there DS0000000915.V309536.R01.S.doc Version 5.2 Page 20 were holes in the cupboards and the doors were old and dated, however there were plans for taking action to address this. The handy person/gardener has commenced employment and was present on the day of inspection undertaking some decorating. The inspector was informed that Avocet are considering the purchase of a dishwasher for each kitchen to ensure good hygiene practices/infection control and assist the staff team in prioritising service users over domestic chores. DS0000000915.V309536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The current staffing arrangements are sufficient to meet the needs of the service users however further training must be provided and the quantity of supervision needs to improve so that staff are supported and service users needs are met. EVIDENCE: There have been no new staff appointed since the previous inspection, however the inspector is aware that Avocets recruitment practices have significantly improved as has no concerns in this area. DS0000000915.V309536.R01.S.doc Version 5.2 Page 22 6 staff have got NVQ level 2 or above and others are working towards it however out of a staff group of 26 this does not meet the target of 50 , therefore this remains an outstanding requirement from the previous inspection. The manager reported that within Avocet Trust there is a Human Resources section responsible for organising training. Since the previous inspection the manager has completed a training audit and all staff have had an individual appraisal however from examination of records and discussion with the manager it was apparent that although staff were up to date with the majority of mandatory training this still did not include infection control. All of the staff had fully completed the appropriate medication training. New staff are supposed to complete Learning Disability Award Framework – accredited training to meet the Sector Skills Council targets for staff induction. New staff were doing so and the manager reported that four staff still needed to complete this, therefore this remains an outstanding requirement. Staff had still not received updated training in the protection of vulnerable adults although the manager intended to cascade this training and as detailed elsewhere in this report staff appeared knowledgeable and were undertaking some good work to protect service users. Supervision was being provided to staff however it was not of sufficient quantity to meet the requirements. This needs to improve to ensure that staff are supported in their job and understand their role and are able to meet service users needs. DS0000000915.V309536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Marfleet lane now has a manager thereby providing the service users with a stable and consistent staff group and lead person to develop the service. Service users live in a comfortable environment however certificates to confirm the safety of the home need to be obtained and all staff need to be up to date with mandatory training to ensure that the health, safety and welfare of service users is promoted. EVIDENCE: The organisation has a clear organisational and management structure in place. Dedicated human resource and administration teams, finance section, health and safety and training teams. There is a chief executive and a service manager. DS0000000915.V309536.R01.S.doc Version 5.2 Page 24 The organisation is a registered charity and as such is audited by the charity commission, there is a dedicated finance manager and the organisation is financially viable. All insurance cover is in place. A new manager has been appointed to the home. He has experience of managing a care home for people with a learning disability and well developed knowledge and experience of working with people with a learning disability. He has completed the NVQ level 4 and the Registered Managers Award. The manager needs to be registered with the CSCI for this home. Policies and procedures have all been reviewed and amended and now meet the requirements. The QA procedure has been implemented into the home and service users, staff and stakeholders have been consulted on the running of the home. Areas for improvement have been identified and are being attended to. There were records available to support that gas safety were safe. Water temperatures were being taken and the home had a fire risk assessment and fire drills were being undertaken, however all staff need to be up to date with all mandatory training. The home did not have an up to date electrical hard wiring certificate and a check for legionella had not been undertaken. There were no certificates to confirm that the baths and equipment had been serviced. These areas all need urgent attention, however the manager immediately contacted the relevant people to ensure that this was addressed. The manager informed the inspector that the breadth and scope of his management responsibility (he manages two care homes for Avocet trust) can create some difficulties and that he feels both of the homes, staff and service users now need a period of stability in the management arrangements. A couple of relatives commented that they are not aware of the complaints procedure and that they have not seen copies of inspection reports, it is recommended that the manager should ensure that relatives are made aware. DS0000000915.V309536.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 3 2 3 3 3 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 4 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 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 x 3 x x 2 x DS0000000915.V309536.R01.S.doc Version 5.2 Page 26 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA19 Regulation 13 Requirement The registered person must ensure that service users complex health needs are met by the provision of health screening, health action plans and access to health professionals. The registered person must ensure that all staff receive training in the protection of vulnerable adults. (Timescale of 30/10/05 and 31/03/06 not met) The registered person must ensure that at least 50 of staff are qualified to NVQ level 2. (Timescale of 1/12/05 and 31/03/06 not met) The registered person must ensure that all staff are up to date with mandatory training and this must include Infection control. (Timescale of 30/9/05 and 31/03/06 not met) The registered person must ensure that a training plan is developed for the staff team. (Timescale of 30/9/05 and 31/03/06 not met) DS0000000915.V309536.R01.S.doc Timescale for action 31/12/06 2. YA23 13 (6) 31/12/06 3. YA32 18 31/03/07 4. YA35 18 31/12/06 5. YA35 18 31/12/06 Version 5.2 Page 27 6. YA35 18 7 YA36 18 8. 9 YA37 YA42 18 23 The registered person must ensure that all new staff receive induction training that meets LDAF standards. (Timescale of 30/9/05 and 31/03/06 not met) The registered person must ensure that all staff receive supervision a minimum of six times per year. The registered person must ensure that the manager is registered with the CSCI. The registered person must ensure that the home has certificates for the safety of; Electrical hard wiring Legionella Baths/equipment servicing 31/03/07 31/03/07 31/03/07 31/12/06 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 Refer to Standard YA22 Good Practice Recommendations The registered person should ensure that relatives are aware of the complaints procedure and that copies of the inspection reports are made available. DS0000000915.V309536.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000000915.V309536.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!