Inspection on 12/08/08 for 68 High Street

This inspection was carried out on 12th August 2008.

CSCI found this care home to be providing an Adequate service.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

68 High Street 07/09/07

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

CARE HOME ADULTS 18-65 68 High Street 68 High Street Loscoe Nr Heanor Derbyshire DE75 7LF Lead Inspector Janet Morrow Unannounced Inspection 12th and 14 August 2008 04:00 th 68 High Street DS0000069782.V370094.R02.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 68 High Street DS0000069782.V370094.R02.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. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 68 High Street Address 68 High Street Loscoe Nr Heanor Derbyshire DE75 7LF 01773 533075 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) M & A Dispensing Chemist Ltd Janet Wain Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Learning disability - Code LD The maximum number of service users who can be accommodated is 3 2. Date of last inspection 7th September 2007 Brief Description of the Service: 68 High Street, Loscoe, is a small care home registered for up to 3 people with a learning disability. The Home is a terraced house, situated in a residential area, on a main road. Each service user has their own single bedroom. The Home has not been adapted for people with physical difficulties and it has steep stairs leading to the bedrooms and bathroom. The Home has a small staff team operating on a rota basis, providing one member of staff on duty at all times when service users are at the Home. The current service user group all have a moderate to mild learning disability so that the Homes service are geared up to high levels of independent activity. There is parking space for one car. Verbal information supplied in August 2008 stated that the weekly fees were £358.65. Copies of inspection reports can be provided by the manager of the home and are available on the Commission for Social Care Inspection website at www.csci.org.uk 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection visit took place over two days for a total of 4.75 hours and concentrated on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. Two concerns had been raised with the Commission for Social Care Inspection since the last inspection visit in September 2007; one related to managerial and staffing arrangements and one related to a slow response to rectify a lack of heating and hot water in winter. The manager was present on the second day of the inspection visit. One member of staff was spoken with and three people currently accommodated in the home were also spoken with. One visiting professional and one relative were spoken with by telephone after the inspection visit. Eight surveys were returned to the Commission for Social Care Inspection prior to the inspection visit; three from people living at the home, three from relatives and two from staff. Care records, a sample of policies and procedures and staff information were examined. A tour of the building took place. The home had not provided an annual quality assurance assessment within designated timescales prior to the inspection visit but provided this shortly afterwards. What the service does well: Individual written needs assessments were in place before people were admitted to the Home so that their diverse needs were identified and planned for. There were also up to date plans of care, which demonstrated that their health, personal and social care needs were being met. The environment was comfortable and well maintained. There were a range of age appropriate activities for people living in the home and independence and decision-making was well managed. All three people living at the home said they ‘liked it’ and a relative said that they thought the home seemed ‘very settled’. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 6 Staff were supported in their day to day work and there was a stable staff team that ensured consistency of care. A staff survey commented that the service did well at keeping people ‘happy and settled’. Relatives’ surveys stated that the home ‘encouraged independence’, that ‘they give the residents confidence’ and that ‘I am very happy with the care’. What has improved since the last inspection? What they could do better: There must be a clear mechanism for recording complaints and the action taken in response to them to ensure peoples’ concerns are addressed. The manager must receive updated training in food hygiene and moving and handling and all staff must undertake safeguarding adults training to ensure the safety of all in the home. The home’s policy and procedures on safeguarding adults should be amended to reflect current safe practice. Recruitment practice must be improved to ensure that all the information required legally by the Care Homes Regulations 2001 is in place before staff commence work at the home. This is to ensure the safety of people living in the home. The staff rota should consistently record the manager’s hours at the home. Care plans, including risk assessments should be reviewed more regularly to ensure staff are acting on up to date information. Medication practice should be further improved by explaining the use of codes on the medication administration record (MAR) charts and by obtaining an up to date copy of the Royal Pharmaceutical Society Guidelines on administering medication in care settings. Quality assurance processes should be improved by obtaining the views of visiting professionals and relatives. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 7 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. 68 High Street DS0000069782.V370094.R02.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 68 High Street DS0000069782.V370094.R02.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was sufficient pre-admission information available to establish that the home was able to meet peoples’ needs. EVIDENCE: All the people living at the home had been admitted through the Local Authority care management system and assessment information was available from that process. The home had also completed its own documentation. Individual care plans were in place based on an initial assessment of each person’s needs. There were risk assessments in place that took into account individual needs and indicated risks that people chose to take and how they were managed safely. All three surveys from people living at the home responded that they received enough information about the home before moving in and all three relatives’ surveys responded that they ‘usually’ received enough information to make 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 10 decisions. Two relatives’ surveys responded that the home ‘always’ met their relatives needs and one responded that it ‘usually’ did. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning and the promotion of independence ensured that people could make individual choices and manage any risks safely. EVIDENCE: Two peoples’ care files were examined and showed that a care plan was in place that demonstrated how individual needs would be met. These were detailed and informed staff how to manage any difficult behaviours as well as how to assist and encourage with daily activities, such as personal care. Both files examined contained sufficient information to enable care to be delivered in a consistent way. Information ‘Front sheets’, ‘likes and dislikes’ lists and Personal Log Sheets were in place and there was also useful information available in the daily communication book. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 12 An annual review of care took place with the funding authority and relatives were also invited to this meeting. However, one person’s care plan had not been updated following new information being made available at the review meeting and the last internal review by the home staff had been in July 2007. Discussion with staff showed how some people made decisions and choices and had relatively high degrees of independence in certain situations, including the use of public transport and in personal finance. Discussion with people living in the home showed that they were able to make decisions and choices about their daily routines and spent their free time in activities of their own choosing. Two surveys from people living in the home responded that they ‘always’ made decisions about what to do each day and one responded that they ’sometimes’ did. Risk assessments were also available that showed how identified risks were minimised and included an environmental assessment as well as for individual problem areas, such as using public transport. However, all the risk assessments were last reviewed in September 2006. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided activities and services that were age-appropriate and valued by people and promoted their independence. EVIDENCE: People living at the home were able to say how much they liked the activities they were involved in; this included a variety of hobbies such as dancing, computer games, music and sport. They went out most days to a local day centre, visiting family and one person had a part time job at a local golf club. A holiday was planned and all were looking forward to going. The range of options available showed that effort was made to structure activities around individual likes and dislikes and in areas that had the capacity for personal development. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 14 The home encouraged independent use of public transport and two service users frequently used it. Regular use was made of a local gym, cinema, shops and pubs. All three surveys from people living in the home responded that they were able to do what they wanted during the day, in the evenings and at weekends. Staff spoken with stated that routines in the home promoted peoples’ independence. These included housework, shopping, ordering food at a restaurant and using cash cards. She added that staff and people living in the home undertook household jobs together and that routines were flexible and reflected individual needs and wishes. This was confirmed by people living in the home who stated that they received the assistance they needed with household chores. Two relatives’ surveys responded that the home ‘always’ helped their relative keep in touch and one responded that it ‘usually’ did. One relative spoken with said they thought their relative was ‘developing’ and that they were ‘happy’. Food stocks in the kitchen were at a good level. There was evidence of peoples’ individual tastes being catered for – with food bought by themselves placed on labelled shelves in the kitchen wall cupboards. All people spoken with were positive about the food they ate. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health care needs were generally met although more improvements to medication administration practice would minimise risk of errors. EVIDENCE: The Home had flexible routines based on peoples’ assessed needs, stated preferences and activities being undertaken. Staff had good knowledge of peoples’ individual preferences and interests and people spoken with said they ‘liked the staff’ and found them ‘helpful’. During the inspection visit, it was observed that privacy and dignity was observed; each person had their own key to their bedroom door and staff were observed to knock before entering. All the people living in the home were receiving regular chiropody, dental and optician appointments. They also regularly attended local clinics for personal 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 16 health needs such as diabetes and asthma. Medical appointments and outcomes were well recorded. Comprehensive records of health appointments had been made on each service user’s Personal Log Sheets. The home had recently obtained personal health files for each individual, which they intended to put into use. Weight was recorded regularly. All three relatives’ surveys responded that they were ‘always’ kept up to date wit important information about their relative and one said that they were ‘looked after’. A staff survey commented that the service did well at ‘supporting the well being of each individual’. Medicines were being kept securely in a locked wall cabinet in the laundry/utility room. However, there was no double locking facility available for the secure storage of controlled drugs should they be required. Two of the three people had medicines prescribed for them and they selfmedicated with support from staff. Both medication administration record (MAR) charts were examined. These were signed accurately and codes used, although the use of the code ‘O’ was not explained on the chart. Staff spoken with stated that one medicine for one person had been discontinued but this was not marked as discontinued on the chart. This had the potential to cause confusion and/or errors. Homely remedies were kept separately and records of what was administered were maintained in a separate book. The home did not have a copy of the Royal Pharmaceutical Society Guidelines, or a copy of an up to date medicine reference book, although this was available at the provider’s other home nearby. Medication training had been undertaken via an in-house training video, a copy of which was available in the home. There were specimen staff signatures available and a photograph to aid identification of each person. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inconsistencies in complaints and safeguarding procedures did not fully ensure the safety of people living in the home. EVIDENCE: The content of the home’s complaints procedure was satisfactory and stated that complaints would be responded to within fourteen days. However, there was no mechanism for recording any complaints or what action had been taken to resolve them. The manager stated that no complaints had been received at the home since the last inspection in September 2007. People living in the home stated that they would discuss any concerns with the staff and manager and thought that they would ‘sort things out’. Two relatives’ surveys responded that they knew how to complain but one responded that they did not know. One survey commented ‘all I know is that I could get in touch with the council care manager’; this indicates that the relative concerned was not aware of the home’s complaints procedure. Two surveys from people living in the home stated that they ‘always’ knew how to make a complaint and one responded that they ‘sometimes’ did. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 18 There had been a concern raised by the Local Authority during November 2007 about a lack of hot water and heating in the home. There was a slow response from the owners to rectify this initially, Although this put right and there were currently no further concerns about heating arrangements, the complainants were concerned about the length of time taken to rectify the problem. The Commission for Social Care Inspection were alerted to a second concern in November 2007 about staff support and managerial arrangements in the home. This was addressed satisfactorily at the time. The financial records of personal allowances for people living in the home were examined. These showed that the person concerned was signing the record with the staff member. The cash held corresponded correctly with the written record and was stored securely. The home had an ‘Adult Protection Procedures and Prevention of Abuse’ written policy as well as copies of the statutory Safeguarding Adults Procedure. The home’s policy stated that people living at the home had a right to withhold consent to a referral being made to the Local Authority following suspicion of abuse. This is not acceptable as the Local Authority are the lead agency for dealing with suspicions of abuse. This was raised as an issue at the last inspection in September 2007. Staff spoken with were aware of their responsibility to report any suspicions of abuse but had not received any training in safeguarding adults. The written information supplied by the home stated that one of the improvements the home intended to make was providing safeguarding training for all staff. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises were well maintained, providing homely, safe and comfortable accommodation for people living there. EVIDENCE: The home provided people living there with a homely and domestic environment. It was clean and well maintained, apart from the staff sleep in area that had a current problem with a tap leak and needed refurbishment. Staff spoken with stated that there were plans to improve this space. This was also confirmed on the written information supplied by the home. It also specified the refurbishment that had taken place such as a new boiler being fitted, re-decoration of all downstairs rooms and new carpets, curtains and light fittings being provided. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 20 To the rear there was a conservatory, patio and small garden. Each person had their own bedroom, with a door that locked if they wished. The bedrooms were seen on this inspection and were well personalised, although small in size. One person said they wanted ‘more space’. All three surveys from people living in the home responded that the home was ‘always’ fresh and clean and one commented that ‘we all help to keep the house clean’. The home was clean and hygienic and there were no unpleasant odours. Laundry facilities were domestic. Discussion with staff demonstrated that they were familiar with infection control procedures and had supplies of gloves and aprons. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment practices did not fully ensure the safety of people living in the home. EVIDENCE: There had been concerns raised since the last inspection visit in September 2007 about staffing and the managerial arrangements at the home, which indicated that the manger was spending insufficient time at the home. This had been resolved with an arrangement that the manager spend a specified number of hours at the home. The staff rota was examined and showed that there was one staff member on in the morning and one from 3pm through to the next morning. The manager’s name was included on the rota. However, for the week of the inspection visit, it did not say that she was present at the home. The previous week had specific times marked on the rota and staff spoken with confirmed that the manager had been into the home at least twice in the previous week. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 22 However, given previous concerns raised, the manager’s hours must be clearly recorded on the rota on a consistent basis. Both staff surveys responded that there were ‘always’ enough staff to meet individual needs. There had been no new staff employed since the last inspection visit in September 2007. The written information supplied by the home stated that ‘no one is employed until two references have been received’. However, when one staff file for an existing member of staff was examined, this showed that some of the information required by Schedule 2 of the Care Homes Regulations 2001 was missing. This included identity information, a full employment history and two written references. A Criminal Record Bureau (CRB) check was in place. Insufficient information at the point of recruitment was raised as an issue at the previous inspection visit in September 2007 and continued failure to obtain such information could lead to legal action being taken. The home had improved its induction process by using the ‘Skills For Care’ Common Induction Standards and the staff file examined showed that the staff member concerned was receiving supervision on a regular basis, with records showing it had occurred in January 2008 and April 2008. Both staff surveys responded that they ‘regularly’ received the support they needed and both commented that they received the training they needed, although one stated that ‘I would like more training’. Training information in the file examined showed that mandatory health and safety training and medication training had occurred since the last inspection in September 2007. Staff spoken with stated that they felt there was good support and training available and gave an example of how information related to a particular disability had been accessed. They also stated that they had attended seminars on learning disability, hearing impairment and dental care. The written information supplied by the home stated that three staff members at the home had achieved or were undertaking an National Vocational Qualification at level 2 or above. This meant that the home was meeting the target of having 50 of staff qualified to NVQ level 2 or above. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well run in the best interests of people living there. EVIDENCE: The manager was registered with Commission for Social Care Inspection and was undertaking the Registered Managers award. Although she spent more time at the company’s other home, staff reported that she did spend sufficient time at the home to offer the support they required. Staff spoken with commented that the home ran ‘smoothly’. One relatives’ survey said they found the manager ‘helpful’. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 24 Quality assurance processes needed further development. The owners were undertaking monthly audits, as required by Regulation 26 of the Care Homes Regulations 2001, and records of these visits showed how they intended to improve. However, there had been no recent surveys to gain the views of relatives or visiting professionals, although the records of the July audit indicated that this was due, and there was no annual plan of how they intended to improve the service. This was raised as an issue at the previous inspection in September 2007. Although there were no certificates available at the time of the inspection, the diary maintained by staff showed that maintenance checks took place. It showed that portable appliance testing had taken place in March 2008 and that gas safety checks were booked for August 2008. This was confirmed on the written information supplied by the home. Staff received mandatory health and safety training and records showed that fire safety and health and safety training had occurred in September 2007 and food hygiene and moving and handling in November 2007. However, the manager’s training in food hygiene and moving and handling was out of date. Cleaning materials were being securely stored in the utility room. 68 High Street DS0000069782.V370094.R02.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 X 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X 68 High Street DS0000069782.V370094.R02.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 YA20 Regulation 13 (2) Requirement A secure double locking facility must be provided to recommended specifications to ensure the safe storage of controlled drugs. There must be a mechanism on place to record complaints and the action taken in response to them. This is to ensure a clear audit of how complaints are addressed and to ensure that peoples’ concerns are taken seriously. Timescale for action 30/11/08 2. YA22 22 (3) & (4) 31/10/08 3. YA23 13 (6) All staff must receive 31/12/08 training in safeguarding adults to ensure that people living in the home are safe. 14/09/08 4. YA34 19(1)(b)Schedule Staff must not be employed 2 unless required information and documents, relating to their recruitment, are in place. This is necessary to ensure the safety of people living in the home. DS0000069782.V370094.R02.S.doc 68 High Street Version 5.2 Page 27 Previous timescale of 01/10/07 not met. Timescale extended by one month from inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA1 YA6 YA20 YA20 Good Practice Recommendations The Home’s Service Users Guide should be in a format suitable for the individual service users. All care plans, including risk assessments, should be reviewed at least six monthly. A discontinued medicine should be clearly labelled as such on the medication administration record (MAR) chart. The home should obtain a copy of the Royal Pharmaceutical Society Guidelines on medicine administration in care settings. There should be an explanation of the code ‘O’ when used on medication administration record (MAR) charts to minimise risk of errors. The Home’s ‘Adult Protection Procedures and Prevention of Abuse’ should be amended to fully reflect safe practices. The staff sleep in area should be refurbished. The manager should consistently record her hours of work at the home on the staff rota. Quality questionnaires should be sent periodically to relatives, staff and external professionals, as well as to people living in the home. An annual plan should be developed, covering all aspects of the running of the Home. DS0000069782.V370094.R02.S.doc Version 5.2 Page 28 5. YA20 6. 7. 8. 9. YA23 YA24 YA33 YA39 10. YA39 68 High Street 11. YA42 The manager should update her food hygiene and moving and handling training. 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 68 High Street DS0000069782.V370094.R02.S.doc Version 5.2 Page 30 - 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!