Inspection on 04/01/07 for 6 Queensview Crescent

This inspection was carried out on 4th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

6 Queensview Crescent 14/07/08

6 Queensview Crescent 18/03/08

6 Queensview Crescent 30/01/06

6 Queensview Crescent 23/09/05

6 Queensview Crescent 29/03/05

6 Queensview Crescent 22/09/04

6 Queensview Crescent 12/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 6 Queensview Crescent Warley Road Scunthorpe North Lincolnshire DN16 1QN Lead Inspector Ms Matun Wawryk Unannounced Inspection 4th January 2007 09:00 6 Queensview Crescent DS0000002872.V308599.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 6 Queensview Crescent DS0000002872.V308599.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. 6 Queensview Crescent DS0000002872.V308599.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 6 Queensview Crescent Address Warley Road Scunthorpe North Lincolnshire DN16 1QN 01724 270407 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.dimensions-uk.org Dimensions (UK) Ltd Undergoing Registration Process Care Home 6 Category(ies) of Learning disability (6), Physical disability (3) registration, with number of places 6 Queensview Crescent DS0000002872.V308599.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2006 Brief Description of the Service: 6 Queensview Crescent is a care home providing personal care and accommodation for six adults aged 18-65 years with learning difficulties. The care home is owned by Dimensions (UK) Ltd and is situated close to two other homes owned by that company. The home is located in a residential area close to the centre of Scunthorpe. It is close to local shops, amenities and public transport. The home is a purpose built bungalow. All the bedrooms are single; bedrooms are fitted with wash hand basins. Bedrooms are decorated and furnished to meet individual service users requirements and preferences. Communal areas of the home are decorated and furnished in a domestic style. Aids and adaptations are provided as required to meet service users’ needs. Information on fees can be obtained from the manager of the home. Information on the service is made available to prospective and current service users via the statement of purpose, service user guide and inspection reports, copies of these documents can be obtained from the manager. 6 Queensview Crescent DS0000002872.V308599.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first key inspection of 2006/07. The inspection visit took place over 1 day in January 2007. Mrs Matun Wawryk, Regulation Inspector carried out the site visit. Prior to visiting the home the inspector sent out a selection of survey questionnaires to all the service users and staff and some professional staff. Comments received were analysed on their return and any issues identified were checked out during the inspection visit. Following the inspection visit questionnaires were also sent to some relatives. Some of the comments received by people have been included in the report. Information received by the Commission since the last inspection was also considered in forming a judgement about the overall standards of care provided by the home. The home was full on the day of the inspection visit. Most of the service users had limited verbal communication skills; therefore the inspector spent time with service users observing activities instead of conducting formal interviews. The manager was not at the home on the day of the visit. In the absence of the manager discussions were held with two support workers who were working in the home at the time of the visit. The inspector checked to see that service users privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured service users were safe and protected in their environments. Documentation in relation to the assessments people had prior to the admission to the home and support plans produced to meet assessed needs were examined. In addition the inspector also looked at a number of records in relation to medication practices, complaints management, staffing levels, staff training, induction and supervision. The inspector also looked at how the home was managed overall. What the service does well: The home ensured service users and their carers received good and timely information about the home. This means prospective service users and their carers have access to sufficient information to enable them to make informed decisions about the homes capacity to meet their needs. Individual support plans for service users are comprehensive and reflect all areas of identified needs. This means staff have access to all necessary guidance to tell what help the persons needs, when they need it. 6 Queensview Crescent DS0000002872.V308599.R01.S.doc Version 5.2 Page 6 Service users had good access to professional medical staff and were able to access external services such as dentists and opticians. There remains a core group of staff that had worked in the home for a number of years. This means service users generally receive care and support from staff they are familiar with. Discussions with the staff indicated that the staff are very committed to their role and take an interest in the welfare of the service users. Staff spoken to during the inspection talked about the service users in a sensitive and respectful way and understood the need to promote their dignity and independence. Staff stated that they felt the service was generally well managed and commented on the approachability of the manager and senior staff. What has improved since the last inspection? What they could do better: Individual support plans were in place for service users and these set out the health and personal care needs identified for each person. Work now needs to be completed on developing the support plans and risk assessments in more suitable formats as one means of further improving the accessibility of these important documents for service users. The home was not regularly checking the temperature of the drugs cupboard. This should now happen, as it is important that medication is stored at the right temperature. On checking a sample of medication administration the inspector noted some handwritten (transcribed) medication had not been counter signed by a second person. In order to ensure proper safeguards are in place a second member of staff should witness all hand written records on Medication Administration Record charts. The manager must ensure all staff are provided with adult protection training. This is needed to ensure staff fully understand adult protection matters and to ensure they understand the local arrangements for reporting allegations or suspicions of adult abuse. 6 Queensview Crescent DS0000002872.V308599.R01.S.doc Version 5.2 Page 7 The inspector would like to thank everyone who completed a questionnaire and/or took the time to talk to her during this inspection. Your comments and input have been a valuable source of information, which has helped create this report. 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. 6 Queensview Crescent DS0000002872.V308599.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 6 Queensview Crescent DS0000002872.V308599.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 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives were provided with sufficient information to help them decide if the home was right for them. Arrangements were in place to ensure prospective service users needs are properly assessed and planned for. EVIDENCE: There had been no new admissions to the home in the last four years. Assessment of this outcome group was based on available records, feedback from staff and relevant policies and procedures. A statement of purpose and service user guide was available and a copy of this document was in place in all service user files looked at during the visit. The service user guide had been reproduced using symbols to improve its accessibility for service users. Arrangements were in place to ensure that prospective service users needs are properly assessed and planned for prior to admission. Two-service user care files were looked at, both contained completed needs assessments. Information contained in these had been used to inform the service users individual support plans. 6 Queensview Crescent DS0000002872.V308599.R01.S.doc Version 5.2 Page 10 Staff members spoken to were aware of the process of information giving to prospective service users, and they knew where the statement of purpose and service user guide information is within the home. The home routinely provided statements of terms and conditions on an annual basis to all service users, which included information on charges. Discussion with staff showed they were very knowledgeable about the care and Staff members spoken to were knowledgeable about the needs of each service user and had a good understanding of their specific needs and the care to be given on a daily basis. None of the service users were able to tell the inspector about their care needs and the input they required from staff. Four professional staff returned a questionnaire; all stated they considered the level of care provided to be good. 6 Queensview Crescent DS0000002872.V308599.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care and support each service user needs and receives is documented and care provided is based on assessment of individual needs and choices. Care plans now need to be produced in more suitable formats for service users. EVIDENCE: Case tracking took place for two service users. The methodology used was a physical examination of care plans, written surveys to service users, staff, and some health and social care professionals, and direct observation on the day of the inspection visit. The home had made significant progress in developing essential life plans for the service users. Two of the plans examined were found to be very detailed and person centred. 6 Queensview Crescent DS0000002872.V308599.R01.S.doc Version 5.2 Page 12 Individual support plans were in place for the two service users selected for case tracking and these set out the health and personal care needs identified for each person. Plans looked at had been regularly evaluated and any changes to the care being given was documented and implemented by the staff. There were risk assessment tools for mobility, tissue viability, bed rail provision, medication, nutrition and general issues; all high risk areas identified had been reviewed and care plans were in place to support appropriate care provision. Work now needs to be completed on developing the support plans and risk assessments in more suitable formats as one means of further improving the accessibility of these important documents for service users. Records evidenced regular care reviews were held with the responsible funding authority. Information from the Pre-Inspection Questionnaire, observation and discussion with staff indicated that all of the service users living in the home were white/British. The home is able to support people from a range of cultural and ethnic backgrounds or those with diverse needs following a needs assessment being completed. Placements at the home are open to individuals from all geographical areas. At the current time the home employed a male worker, this enabled service users to have a choice of staff gender when receiving personal care, as far as practicable. 6 Queensview Crescent DS0000002872.V308599.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, 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. Service users are encouraged to maintain links within the community. The routines of the home are flexible to meet individual service user needs and the meals provided to service users are of good quality and offer variety and choice. EVIDENCE: The home does not employ an activity coordinator; support workers are responsible for organising and arranging activity programmes. Records did not evidence that staff had been provided with training in planning and delivering activity programmes for people with complex needs. The inspector advises that consideration should be given to providing this type of training. Some of the service users attended the local authority day service. The home did not have a formal activity programme; staff reported that activities were planned on an individual basis. This included; hands massages and nail care, outings, pub visits and shopping trips. 6 Queensview Crescent DS0000002872.V308599.R01.S.doc Version 5.2 Page 14 Although support plans for social activities were in place, in some cases these needed to be more detailed to better reflect recreational and personal development needs of the individual. More detailed support plans must now be developed linked to assessments of social needs. The manager must, on a regular basis, continue to consult service users about the programme of activities on offer in the home and ensure support plans better reflect the individual preferences and capabilities of the individual. Discussion with staff indicated some service users had regular contact with their families and friends. Staff stated relatives and visitors are made welcome at any reasonable time. Key workers helped service users to maintain family contact by sending cards at significant occasions such as birthdays and Christmas, thereby helping service users to maintain family contacts. Four professional staff returned a questionnaire; all commented that they were satisfied with the overall care provided to their client. The standard of the meal provision in the home was good. Service users were provided with three meals a day and records showed that a varied menu was available. Food likes and dislikes were recorded. The inspector spent time in the dining area observing the lunchtime meal. Two service users needed to be assisted to eat their meal and staff did this in a sensitive manner and service users were not hurried. Staff had a good knowledge of the service users food preferences, portion size and manner of eating. 6 Queensview Crescent DS0000002872.V308599.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is offered in such a way as to promote and protect the service users privacy and dignity. Arrangements for meeting the health care needs of service users are satisfactory. EVIDENCE: All the bedrooms are single occupation this means treatments and examinations can be carried out in private. Individual service user support plans described how personal care should be provided to ensure the dignity and privacy of the individual is maintained and promoted All service users were registered with a GP. A record of routine eye tests, dental and chiropody checks had been maintained. Individual support plans detailed how often service users should be weighed; although for one service users this was not happening at frequencies detailed in their individual plan. The manager should ensure this now happens. 6 Queensview Crescent DS0000002872.V308599.R01.S.doc Version 5.2 Page 16 Records showed service users had access to outpatient appointments at the hospital and that staff accompanied the service users where this was needed. Individual health action plans had been introduced into the home and these were to be detailed. This is a positive development, however it’s important that these plans not only detail peoples health needs they should also focus on improving people’s lives. The home uses the Nomad system for drug administration. Management of medication systems in the home were generally satisfactory. None of the service users living in the home at the time inspection visit had been prescribed controlled medication. Medication records were checked for three service users as part of the case tracking process: transcribing records were correct with the medication records corresponding to the printed label on the medication, however a second staff member had not countersigned the record sheet to indicate they have both witnessed that the information on the sheet is correct. The manager should ensure this now happens. There were no signature gaps on the records looked at. Medication storage in the home is very limited; staff should monitor the temperatures in these areas to ensure they do not exceed the manufacturers guidelines. Since the last inspection a programme of in-house medication training had been introduced and this included assessment of competence. 6 Queensview Crescent DS0000002872.V308599.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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a satisfactory complaints system and staff and service users can be assured complaints and concerns will be listened to and acted upon. Adult protection systems need to be supported by a full staff-training programme. EVIDENCE: There have been no complaints made to the Commission or the home in the last twelve months. The home had a clear complaints procedure and the procedure was available in a suitable format for service users. Staff spoken said they had no complaints about the home and felt confident to raise issues of concern if they arose. None of the service users were able to confirm to the inspector their understanding of the complaints process, comments from returned professional questionnaires indicates that they are aware of how to complaint, where this is needed. Information from the Pre-Inspection Questionnaire and discussion with staff identified that the home had policies and procedures to cover adult protection and prevention of abuse, whistle blowing, management of challenging behaviours and management of service users money and financial affairs. Records identified that not all staff had had adult protection training. The need to ensure all staff are provided with this training remains an outstanding requirement from previous inspections and action must now be taken to address this. 6 Queensview Crescent DS0000002872.V308599.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a warm, safe and comfortable environment to live in. Further work need to be carried out in the garden to improve its accessibility for service users. EVIDENCE: A tour of the home was carried out and all areas were seen to be clean, tidy and odour free. Since the last inspection the lounge cum dinning room had been redecorated. All bedrooms looked at were clean and tidy and were furnished and decorated in a homely style. Many people had furnished their bedrooms with a range of personal items, some bringing in items of furniture to reflect their own individual choice and taste. Observation of the premises showed that there are some minor areas still needing work; the lounge carpets and some service users bedroom carpets needed replacing. Cleaning had failed to remove marks and stains. Whilst 6 Queensview Crescent DS0000002872.V308599.R01.S.doc Version 5.2 Page 19 these matters do not pose any health and safety problems they do not ensure service users live in an attractive environment. Staff had taken some action had been taken to partially address the requirement concerning the garden for example; Staff had improved the planting scheme and layout of the garden. The staff are to be commended for this. The garden continues to slope this poses some difficulties for some service users because of problems with mobility. This means service user do not have free access to all parts of their home. The company responsible for the home should now take action to address this. Staff reported that they had access to all required specialist equipment needed to ensure service users needs could be met, this included a hoist, additional moving and handling and specialist bathing equipment. 6 Queensview Crescent DS0000002872.V308599.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home generally provides sufficient numbers of staff on each shift to meet the care needs of service users. Staff are trained and competent to carry out their duties and responsibilities. EVIDENCE: The roles and responsibilities of staff are clearly defined and understood. Two support workers spoken to were able to fully describe the management and reporting arrangements in place in the home. The home was full at the time of the inspection. Two care staff on duty in a morning and in the afternoon and one care staff at night. The manager’s hours are supernumerary to these figures. Staff spoken to said staffing levels were generally although commented that on accessions more staff were needed at key times. Staff said they were generally able to spend quality time with the service users. Five staff returned a questionnaire. In response to the question ‘do you feel there are enough staff on duty to meet the residents needs on all shifts’ two staff answered yes to this question, two said no and one did not give a response. 6 Queensview Crescent DS0000002872.V308599.R01.S.doc Version 5.2 Page 21 All the service users had resided in the home for several years and anecdotal information from staff indicates that the service users needs have changed. There was nothing to show that a review of staffing had been completed, or how staffing levels had been calculated. There was nothing to show if the home was using a specific dependency-rating tool to assist in the calculation of staffing hours. The inspector advises that a formal review of staffing based on assessment of the dependency levels of service users should now be carried out using a recognised tool, this will enable informed judgements to be made about the number of care hours needed to meet the needs of service users. The inspector was not able to check recruitment records for newly appointed staff because the manager was on annual leave at the time of the inspection visit and staff on duty did not have access to these records. This matter will be checked at the next inspection. Previous inspection finding indicates the home follows good recruitment and selection practice. The home had an equal opportunities policy and procedure. Information from the staff indicated indicates that this is promoted when employing new staff and throughout the working practices of the home. The home provides a structured programme of induction training, with all new staff competing a five-day corporate induction programme. It was not evident from discussions with staff whether this covers the Skills for Care Common Induction Standards. The manager needs to carryout a check to ensure the corporate programme reflects skills for Care requirements. One staff member spoken to described their induction training as good. The induction programme included opportunities to work alongside more experienced (shadowing) staff. The inspector was not able to establish how many staff had completed or were enrolled to complete an NVQ, because staff on duty did not have this information. Staff spoken said staff were encouraged and supported to gain appropriate NVQ qualifications. Because of this the requirement concerning a need for the registered person to continue with the NVQ training programme to ensure 50 of care workers achieve an NVQ if not already achieved remains. Staff on duty stated that access to training was very good and records seen confirmed this. A formal staff supervision programme was in place and records evidenced staff received formal recorded supervision. The inspector was not able to formally examined the staff supervision programme. Staff spoken said they were provided with formal and regular supervision. staff indicated that annual appraisals are completed. The inspector was not able to verify this because staff on duty did not have access to these records 6 Queensview Crescent DS0000002872.V308599.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well managed and organised home. Arrangements were in place to ensure service users health and safety was maintained and promoted. EVIDENCE: An area manager currently manages the home. This person is not yet registered with the Commission for Social Care Inspection. Action must now be taken to address this. This is needed to meet legal requirements. The manager has considerable experience of managing the home. Staff spoken to and those who returned a questionnaire said the home was run in the best interests of service users. Staff confirmed that moral was good and staff said there was a good team approach to care delivery at the home. 6 Queensview Crescent DS0000002872.V308599.R01.S.doc Version 5.2 Page 23 Evidence from staff interviews and staff surveys indicated the staff consider the manager to be approachable, staff said she takes issues raised seriously and takes prompt action to resolve matters. Five staff surveys were returned; all commented that they felt the home was well managed and that supervisory arrangements were satisfactory. The home had a range of mechanisms in place to monitor the quality of services provided including regular audits of the homes environment, regulation 26 visits and reports, a staff survey questionnaire and individual service user reviews. As the manager was not available the inspector was not able to establish whether a specific development plan for the home and published report of quality assurance monitoring reflecting the outcomes for service users and feedback from relevant third parties was in place. This matter will be followed up at the next inspection visit. In the meantime the requirement concerning a need to implement a quality assurance programme, which fully meets the requirements of NMS 39 will remain in the report. The home had a range of policies and procedures for health and safety. Safe working practices were maintained by the provision of training to staff in the form of moving and handling, basic food hygiene, first aid and health and safety. The provider information questionnaire states current certificates were in place for the gas, portable electrical appliances and fixed electrical systems. Accident records were completed appropriately and the manager carried out regular audit on these to help spot any problems or recurring themes. 6 Queensview Crescent DS0000002872.V308599.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 3 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 x 34 X 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 x x X X 3 X 6 Queensview Crescent DS0000002872.V308599.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 YA12 Regulation 6 Requirement The responsible person must develop support plans in a more accessible format for service users. Daily records should relate to the support plans. Timescale of 31.3.05, 31/11.05 and 31.3.06 not met. The registered person must continue to consult with service users and or their representatives on a regular basis to ensure service users benefit from activity programmes, which reflect the service users individual needs, preferences and capacities. Service users must be provided with a programme of valued and meaningful activities. Timescale 30.4.06 not met The registered provider should ensure 50 of care staff achieve an NVQ Level 2 or above. The registered person must develop a quality assurance and monitoring system that meets the requirements of this DS0000002872.V308599.R01.S.doc Timescale for action 31/03/07 2 YA12 6 31/03/07 3 OP32 18 31/03/07 4 YA39 24(1a&b, 2,3) 30/03/07 6 Queensview Crescent Version 5.2 Page 26 standard and produce an annual development plan based on a systematic cycle of planningaction-review, reflecting aims and outcomes for service users. Timescale of 19.2.04 and 31.12.05 not met. 5 YA37 8 The registered person must ensure a permanent manager is appointed. Once appointed the manager must submit an application to register with the Commission for Social Care Inspection. Timescale 30.6.06 not met The registered person must have the sitting room carpet and the two stained bedroom carpets replaced. The registered person must develop a tool for assessing dependency levels. This should then be used to assess whether care hours provided in the home are appropriate to enable staff to meet the care and support needs of service users currently living in the home (Timescale of 31.12.05 and 31.3.06 not met The registered person must ensure all staff are provided with adult abuse training. 31/03/07 6 YA24 16 30/03/07 7 YA33 18(1a) 31/03/07 8 YA23 18 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 6 Queensview Crescent DS0000002872.V308599.R01.S.doc Version 5.2 Page 27 1 YA20 Medicines must be stored at the appropriate temperature. A record of temperature must be maintained for all areas where medicines are kept The registered person should ensure a second member of staff should witness all hand written annotations on Medication Administration Record charts. Medicines must be stored at the appropriate temperature. A record of temperature must be maintained for all areas where medicines are kept 2 YA20 3 YA20 6 Queensview Crescent DS0000002872.V308599.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 6 Queensview Crescent DS0000002872.V308599.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. 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