CARE HOME ADULTS 18-65
58 Hermitage Way Madeley Telford Shropshire TF7 5SZ Lead Inspector
Deborah Sharman Key Unannounced Inspection 1st August 2007 09:30 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 58 Hermitage Way DS0000020541.V345398.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. 58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service 58 Hermitage Way Address Madeley Telford Shropshire TF7 5SZ 01952 586224 01952 432209 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) www.care-ltd.co.uk CARE (Cottage and Rural Enterprises Ltd) Ms Jayne Eeles Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide personal care and accommodation (without nursing) for service users of both sexeswhose primary care needs on admission to the home are within the following categories: Learning Disability (LD) 7 The maximum number of service users accommodated is 7. 2. Date of last inspection 1 February 2007 Brief Description of the Service: 58 Hermitage Way is registered with the Commission for Social Care Inspection as a care home for a maximum of 7 adults with a learning disability. Cottage and Rural Enterprises Limited (CARE) own the home. The house is purpose built and is situated on a residential estate close to the towns of Madeley and Ironbridge. The building contains a self contained flat. The Homes Statement of Purpose states that The services provided are designed in consultation with the people who live here and respond to the needs of the individual. Information is shared with service users in the service user guide and formally (during house meetings) and informally on a regular basis. Service users are very proactive in the running of the home and all key decisions are taken only after full consultation. Fees range from £480.69 to £515.87 a week. 58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One Inspector carried out this unannounced key inspection. As the inspection was unannounced this means that no one associated with the home received prior notification and were therefore unable to prepare. As it was a key inspection the plan was to assess all National Minimum Standards defined by the Commission for Social Care Inspection as ‘key’. These are the National Standards which significantly affect the experiences of care for people living at the home. Information about the performance of the home was collated in a number of ways. Prior to inspection the Manager provided the Commission for Social Care Inspection with written information and data about the home in their annual return. At the same time, using questionnaires, the Commission for Social Care Inspection sought the views of people living at the home and those of their relatives and other professionals associated with the home. These written comments were returned to the Inspector. Comments were received from five out of seven people living at the home. Written feedback was also received from four sets of parents and one medical professional. All of this information provided prior to inspection helped to formulate a focus and plan for this inspection and has helped in determining a judgement about the quality of care the home provides. During the course of the inspection that began at 9.00am and concluded at 6.00pm the Inspector used a variety of methods to make a judgement about how service users are cared for: The Manager whose day off it was on the day of inspection came in and supported the inspection during the afternoon. Staff work alone and the staff member on duty in the morning supported the inspection process and was interviewed by the Inspector. All of the people who live at the home were out during the day but the Inspector was able to chat in detail for an hour to a group of three people who live there before they went out. They were able to give the Inspector a very clear picture of what it is like to live at Hermitage Way. They very clearly articulated how much they like living there. The Inspector assessed the care provided to one service user in detail using care documentation and sampled aspects of care provided to one other. The Inspector also sampled a variety of other documentation related to the management of the care home such as staff supervision, maintenance of the premises, accidents and complaints. Staff training was assessed by talking to staff, using pre inspection information from the manager and by talking over the phone on the day of inspection to the company’s training coordinator. The Inspector returned the following day,
58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 6 to assess how new staff are recruited as this information is stored off site. The Inspector was able to observe service users preparing for the day, tour the premises, was invited by a number of people living there to see their bedrooms including the separate flat, observed tea being served and observed the administration of medication to one service. What the service does well: What has improved since the last inspection?
Since the last inspection a new Manager who has previously worked at the home and therefore knows the service users well has returned to post and has since become registered with the Commission for Social Care Inspection (CSCI). This is a popular decision with the people living at the home who recognise that things have started to improve for them. One service user said that she visits them and listens to and sorts out any problems they may have. Other service users agreed with this. An Assistant Manager now supports the Manager and this is a new post. Management support is therefore better available to the home in the absence of the Registered Manager. Morale at the home amongst staff and people living there has improved. The Manager also believes that relationships with outside agencies are improving. One service user whom the home was struggling to meet the needs of, has
58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 7 temporarily moved out of Hermitage Way and this has had a positive impact on others living at the home. The Management team have worked hard since the last inspection to review medication practice and there were no concerns about medication identified at this inspection. This serves to better promote service users health and safe guard them from the risk of accidental under or over dose. How holidays are arranged has been reviewed to provide service users with better choices of holiday destinations and companions. 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. The summary of this inspection report can be made available in other formats on request.
58 Hermitage Way DS0000020541.V345398.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 58 Hermitage Way DS0000020541.V345398.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): Quality in this outcome area is good. Appropriate procedures are in place that would enable the successful admission of a new service user to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no new admissions to the home since the time of the last key inspection therefore the judgement made at the time of the last inspection is carried forward. 58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is adequate. Service users are knowledgeable about their individual support needs and how to take assessed risks during everyday life however they are vulnerable if written plans and assessments are not comprehensive and current. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users who spoke with the inspector identified what support needs they had and were happy that staff met those needs. They said that they felt all their needs are met. Service users are aware of their own care plans and how risk assessments support them to undertake tasks safely. They were able to recall a range of risk assessments that are in place and the control measures to minimise risk when for example using the cooker amongst other things. They said that they do not feel prevented from taking reasonable risks and
58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 11 described a number of things that they do independently such as going for walks. Perusal of some risk assessments for individuals showed them to be generalised in protocol style format without assessing the level of risk posed to that individual and ways of reducing the risk. On the whole care plans are in place to identify individual support arrangements based upon individual preferences, needs and routines. Care plans have been reviewed and are reviewed monthly by key workers and annually by multi disciplinary partners including the service user. The Manager undertook to ensure that the multi disciplinary reviews are arranged six monthly rather than annually to comply with the National Minimum Standard. One service user has developed a significant health need and records viewed traced symptoms back to at least November 2006. This has impacted upon the service users personal and environmental hygiene. The problem has not been medically assessed quickly enough and therefore how to support the service user to manage the problem is not known. Written guidance developed in November 2006 does not satisfactorily address the issues, as the cause is not known. Response has therefore been superficial. Reviews of care plans must result in new needs being included and required care intervention made explicit. Service users are consulted in all aspects of the running of the home and were able to share with the inspector numerous examples of how their wishes and opinions are listened to. 58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 12 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, 17. Quality in this outcome area is excellent. Service users lead full and active lives while receiving the support they need. They are fully in control of their lives and the leisure services they receive This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Inspector joined three service users for a chat at the dining table whilst one service user was taking responsibility for recording others meal orders for the day. During an informal group discussion these service users told the inspector about numerous activities that they participate in on a regular basis. One service user said he likes Hermitage Way because he said ‘we are more independent. We can do things for ourselves like cooking, washing up and housework’. He went onto say that he had just started to work at a café and was very much enjoying it. Another service user also described how she works in a different café and the third service user said how she was desperate to
58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 13 have a job also. The providers quality assurance surveys for 2006 show that 60 of Ironbridge respondents attend college and 24 are in unpaid jobs with 1 being in paid work at least one day per week. Service users also described a range of community activities they take part in and holidays they have enjoyed and are looking forward to. They all confirmed that they vote. It was particularly positive to hear the service users describe their own goals and dreams for the future. All service users stated that they manage their own money and described how they stay in touch with family and friends in a variety of ways through visits, letter and phone calls. Written records monitor that service users are having contact with the people important to them and this is also confirmed in relatives’ feedback. When the Inspector arrived at 9am she observed a service user using the payphone. All service users who spoke with the inspector stated that they enjoy a healthy diet. Everyone has the opportunity to do the cooking and service users can prepare something different if they do not like what is on the menu. Service users take part in food shopping and praised the quality and quantity of food available to them. The Inspector saw service users enjoying their tea together. 58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 14 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, 20. Quality in this outcome area is adequate. Service users health and personal care needs are mostly met well. Omissions identified for one service user have reduced this overall rating to adequate because the health, comfort and dignity of the service user have been compromised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans inform staff how service users prefer their personal care to be managed and personal routines are specified in detail. Discussion with a staff member showed that she was aware of how to provide care in accordance with the written guidance available. Service users said they are aware of their care plans, are involved in developing them and are satisfied with them. All service users who have provided feedback to CSCI are satisfied with arrangements for their personal care and feel that their privacy and independence are respected. Service users are very able and for the most part can self care with prompts and encouragement in the main from staff. On arrival at inspection in the morning service users were getting ready for the day independently in their
58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 15 own rooms. Service users told the Inspector that they are satisfied with the bathing facilities available to them. From looking at the care of one person in detail and from visiting his / her bedroom it was evident that additional support is required arising from a health need. The matter is now under medical review but there has been a delay in seeking this. Guidance is therefore not available to staff and in discussion with the staff and manager it was clear that the matter is not being proactively managed. Apart from this omission discussion with service users and assessment of records shows that routine health screening is facilitated and that changes in health are responded to. For example toothache resulted in a prompt emergency appointment with the dentist who extracted the tooth. Records also show that a GP request for a blood test was arranged and that the results were followed up and recorded. The Manager and Assistant Manager have worked hard to improve medication systems since the last inspection. Staff believe the system to now be ‘much better’. Medication records are no longer ‘homemade’ and tablets are now supplied to the home in a monitored dosage system. Both these changes serve to minimise the risk of administrative error. Since the last inspection there has been an error in the administration of medication to one person. This arose as a result of confusion stemming from frequent changes in prescribed dose. Since the error, this medication has been included in the monitored dosage system removing the confusion for staff. New risk assessments and protocols are also in place in respect of a service user who self-administers medication following some concerns identified. Clear protocols are now in place for the administration of olive oil to one service user and this is an improvement since the last inspection. Perusal of administration records and stocks of medication indicate that service users are receiving their medication as prescribed. There is no evidence that service users object to staff administering their medication to them when they are unable to do so themselves but the Manager is advised to formally obtain their consent. 58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 16 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, 23 Quality in this outcome area is good. People who live at Hermitage Way feel listened to and are now confident that their concerns are listened to and acted upon. Service users spoken to all feel safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the people living at Hermitage Way who completed CSCI’s survey and returned it pre inspection said that staff always listen to them and take action where necessary. The three people who spoke to the Inspector said that they are happy that Jayne is the manager again because she visits them and helps them to sort out any problems they may have. They told the Inspector that they have regular residents meetings where they can talk about their ideas, feelings and goals. They also explained to the Inspector how they could make a complaint if they need to. The last inspection report states that there was no evidence that a recorded complaint made by a service user had been satisfactorily concluded. This inspection found no record of that complaint and with the change in manager no progress had been made. However, the Manager was aware of the complaint details and had received a subsequent complaint of the same nature from the same service user. There was clear evidence how this had been investigated and dealt with and evidence that the service user was satisfied with the outcome. The Manager in consultation with the service user had dealt with the matter as a concern rather than a complaint. The Inspector advised
58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 17 that concerns are logged centrally as are complaints so trends can be analysed and reported when necessary. All complaints records must be retained. Service users described feeling safe living at Hermitage Way. Staff have received Adult Protection training and discussion with the staff member on duty showed a developed understanding of what abuse is and their role in reporting it should they become concerned about a vulnerable adults well being and safety. There have been no adult protection allegations, investigations, and referrals or staff disciplinaries in the last 12 months. People who live at Hermitage Way are not physically restrained. The staff member on duty who was booked to attend managing challenging behaviour training said she had been informed how to manage and support behaviours. She understood the causes of behaviour that challenges and was able to describe how she would help service users to avoid a level of distress that would lead to behaviour that challenges. She was aware of appropriate action to take in the event of being unable to diffuse the situation. The Inspector was told that nobody uses occasional medication for the management of behaviour. Service users confirmed that they manage their own money and therefore records were not assessed. Inspections of care files however showed there to be financial risk assessments in place. Although there are no concerns about the management of behaviour for the purpose of clarity, consistency and accountability the Manager must ensure that care plans contain suitable guidance detailing how service users behaviour can be positively supported. 58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. Quality in this outcome area is good overall. The premises are comfortable and homely. People who live there like their home, their bedrooms and feel that the facilities available meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises showed it to be clean and safe with no immediately evident hazards. Toiletries are on display in bathrooms but the manager believes this does not present risks to service users who are very able and aware of safety issues. The only aspect that one service user commented on with support from another two was the ‘shabby’ curtains in the lounge and especially the dining room. The Inspector agrees with this as the linings are slashed and the curtains shredded with holes. They detract from an otherwise well maintained communal area. The gardens were tended to on the day of inspection and provide a pleasant outdoor space for service users. A service user enjoys helping with the garden maintenance.
58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 19 Health issues for one service user discussed earlier in this report have resulted in a strong malodour in his / her bedroom. This is not being proactively managed and provides an unpleasant personal space in which to sleep. Action must be taken without delay to address this. The kitchen and laundry are clean. Removing the general storage of coats from the laundry was discussed to comply with better cross infection risk management. 58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is excellent. Staff are recruited safely, are motivated and are well trained. This helps to assure people who live at the home that their assessed needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff, service users and relatives are satisfied with the level of training and competence of staff. Staff were observed to respect service users independence and privacy by knocking on bedroom doors and waiting to be invited in. Discussion with the off site training manager evidenced that staff training is appropriate, up to date and well managed. Male and female service users live at Hermitage Way. This is not reflected in the staff group who are all female. This was discussed separately with both the manager and a staff member who were happy that male service users need for male carers and role models is met within the day services. The Inspector observed this to be the case as one service user helps the maintenance man and was tending the gardens on the day of inspection.
58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 21 Recruitment documents were assessed and showed staff to be recruited safely with all pre employment checks having been received prior to the staff member starting in employment. This serves to protect vulnerable adults. Discussion with staff showed a good detailed understanding of service user need and staff knowledge accorded with information in care plans. A member of staff was less aware of how to meet one aspect of one service users health need. As previously discussed this had not been fully assessed in a timely way and guidance is not yet available to staff. The Manager since her return is endeavouring to improve the frequency of supervision to staff. Assessment of records and discussion with staff showed that she is making good progress. Staff value supervision time seeing it as effective. A staff member praised the support available to her saying that since the new manager has been in post ‘I am much more aware of what is expected of me, and what paper work I need to fill in and I feel more competent. Ive been shown what to do now. Ive had regular supervisions every month and just had an appraisal. Supervisions are very useful. She shows me what Im doing well. She gives me things to do which helps me to learn’. The manager feels that team morale and cohesiveness has improved and praised the commitment of the team who she said have been fantastic in response to the need to make changes. 58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42. Quality in this outcome area is good. The new Manager has made a good start to making the required improvements and plans are in place to address the further improvements needed. People who live there are happy with how the home is being managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The newly registered manager who feels very well supported has been in post for 5 months and has prioritised areas for improvement. This has included delegating responsibility for aspects of work to staff members. One staff member for example is now responsible for coordinating the maintenance needs of the home. 58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 23 Aspects of practice have clearly improved in the short time that the new manager has been in post, medication for example and service users are also happier. Staff spoke highly of the management approach. The home clearly has many strengths and the manager is aware of which areas remain in need of improvement. The Manager was disappointed about the outcomes for the service user case tracked under health and personal care, acknowledged the omissions and stated her commitment to making the necessary changes. The monitoring of water temperatures has improved since the last inspection as temperatures are in range. Basin temperatures are not being monitored and it is unclear whether thermostatic valves are in place. The manager said assessments have shown this not to be a risk but this could not be evidenced for the service user case tracked but was addressed during the course of the inspection. Quotes are being obtained and the situation reconsidered. A legionella test has not been carried out but was booked for the week of inspection. Radiators are low surface and the electric fire, which is rarely used, is guarded. Some risk assessments have been updated and many are still in need of review and improvement. Bathing and COSHH assessments viewed for one service user are not individualised, do not assess the level of risk for that person and contain general good practice guidelines rather than specific individualised control measures. The Manager has reviewed the fire risk assessment but has identified the need to improve it from the review. All fire system checks and services are up to date and regular fire drills have been held. Temperatures for cold and hot foods are being taken regularly and comply with safe ranges. Certification showed that electric and gas equipment has been maintained. The boiler however is slightly over due for a service but the Inspector was assured that this was in hand. There has been one admission to Accident and Emergency and two unrelated minor accidents recorded. All staff are trained in first aid reassuring service users that staff will respond appropriately in the event of an emergency. This is particularly important at Hermitage Way where staff work alone. Although the manager has taken steps to try to improve this, personal service user information is still being recorded in a public way that does not preserve confidentiality. Corporate service user satisfaction surveys are in place and the results of the 2006 survey have just been published. It is not possible to identify satisfaction within individual units / homes from the collated evidence but generally shows high levels of satisfaction amongst service users collectively across the Ironbridge CARE site with small gains and losses across the different performance indicators.
58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 X 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 2 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 3 3 X 2 2 X 58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (2) (b) Requirement Care plans must contain all up to date information to reflect the current needs of service users
Original timescale of 27/02/07 from Inspection February 2007 not met. Timescale for action 31/08/07 2. YA9 13 (4) (c) Risk assessments must be reviewed as required and be updated to support changing needs.
Original timescale of 27/02/07 from Inspection February 2007 not fully met. 31/08/07 3 YA19 12(1)(a) Steps must be taken to make proper provision for all the health and personal care needs of the service user whose care was case tracked. This will protect the service users health, quality of life and dignity.
New requirement arising from this inspection August 2007 31/08/07 4 YA24 16(2)(k) Steps must be taken to keep all 31/08/07 areas of the care home including bedrooms free from offensive odours to provide a pleasant and comfortable environment for the service user that is free from risk
DS0000020541.V345398.R01.S.doc Version 5.2 Page 26 58 Hermitage Way of infection.
New requirement arising from this inspection August 2007 5. YA41 17 (1) (b) General records must not contain 31/08/07 personal or private information relating to a service user.
Original timescale of 27/02/07 from Inspection February 2007 not met. 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 Care plans should be reviewed with the service user, significant professionals and family, friends and advocates as agreed with the service user at least every six months
New recommendation arising from this inspection August 2007 2 YA20 It is recommended that written consent for the administration of medication to service users by staff is obtained where possible from service users.
New recommendation arising from this inspection August 2007 3 YA22 Minor complaints that are recorded as concerns should be logged centrally to ensure that they can be monitored, be available for inspection and so trends can be analysed
New recommendation arising from this inspection August 2007 4 YA24 It is recommended that curtains in the lounge should be repaired or replaced and that curtains in the dining room should be replaced.
New recommendation arising from this inspection August 2007 5 YA30 Consideration should be given to storing coats away from the laundry to minimise the risk of cross infection.
New recommendation arising from this inspection August 2007 58 Hermitage Way DS0000020541.V345398.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: 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
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