Inspection on 14/11/06 for 7 Blunt Street

This inspection was carried out on 14th November 2006.

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

Other inspections for this house

7 Blunt Street 12/03/09

7 Blunt Street 07/11/07

7 Blunt Street 25/01/06

7 Blunt Street 06/09/05

7 Blunt Street 17/02/05

7 Blunt Street 22/06/04

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 08/07/2008.

CARE HOME ADULTS 18-65 Blunt Street (7) Stanley Common Ilkeston Derbyshire DE7 6FZ Lead Inspector Tony Barker Key Unannounced Inspection 14th November 2006 09:10 Blunt Street (7) DS0000019941.V319536.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 Blunt Street (7) DS0000019941.V319536.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. Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blunt Street (7) Address Stanley Common Ilkeston Derbyshire DE7 6FZ (0115) 9323491 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.unitedresponse.org.uk United Response Christine Coates Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25th January 2006 Brief Description of the Service: 7 Blunt Street is a semi-detached house in a small village development. Service users are provided with adequate accommodation and single rooms. There is a reasonably-sized rear garden. The Home offers personal and social care to people with a severe learning disability with associated conditions that include autism, sensory disability, epilepsy and challenging behaviour. Activities are planned to meet individual needs. The fees currently range from £1300 to £1500 per week. Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 7.25 hours and was a key unannounced inspection. The service users had high levels of dependency and therefore were not able to contribute directly to the inspection process, though they were observed working with and being cared for by staff. The Manager and Senior Support Worker with Additional Responsibilities (SSWAR) were spoken to and records were inspected. There was also a tour of the premises. One service user was case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The pre-inspection questionnaire was reviewed prior to this inspection. What the service does well: What has improved since the last inspection? The kitchen had a new cooker and was newly refurbished and the lounge had been recently re-decorated. Service users’ records, and other records, were being reviewed to ensure they were up-to-date and records were signed and dated. There had been an overall improvement in the standard of service users’ records. The Senior Support Worker with Additional Responsibilities (SSWAR) post had become full time and the post holder had attended Safeguarding Adults (adult abuse) training from Social Services. A written policy regarding this topic was available to staff. Half of the staff group had a recognised training qualification. Improvements had been made to the environment. Staff had individual training and development programmes. Eight of the fourteen requirements and six of the ten recommendations made at the last inspection had been met. Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 6 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. Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 7 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 Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate information about the Home was mainly available in order for prospective service users and their families to make an informed choice about where to live. Service users had their needs assessed before admission to the Home so that staff could provide individually tailored care. EVIDENCE: The Home’s service users’ guide and statement of purpose had improved – particularly the service users’ guide, through the use of symbols. There was still some work needed in order to fully individualise these documents to the Home. The most recent admission to the Home was in August 2004. This service user’s file contained a range of pre-admission assessments. Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 9 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 good. This judgement has been made using available evidence including a visit to this service. Service users were benefiting from the care planning system but it could be improved. They were making decisions about their lives, with assistance, and were being supported to take risks to improve their independence. EVIDENCE: There were a range of useful documents, relating to each service user, on their individual main file and within the Daily Records File. The latter file gave a day-to-day view of each service user and included a helpful single-page ‘Introduction Sheet’ with Makaton (sign language) symbols, photographs of the service user and their key worker and the service user’s preferred name. The main file of the case tracked service user contained ‘Definitions of positive and negative behaviour’, medical and finance records, review notes and ‘Routines’. The latter provided a list of goals and tasks for staff. However, although this ‘Routines’ document provided useful guidance for staff it could not be considered to be a holistic care plan -that is, a document setting out in detail the action that needs to be taken by staff to ensure that all aspects of each service user’s health, personal and social care needs are met. The Manager showed the Inspector a document called ‘Listen to Me Workbook’ that included Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 10 the individual’s ‘likes and dislikes’, ‘hopes and dreams’ and ‘changes I’d like to make’. Both agreed that once this document is completed, and in use, it should provide a holistic, ‘person-centred’ approach to care planning. It was noted that individual service user records had been kept reviewed, up-dated and signed. However, as at the previous inspection, the minutes from the most recent care plan review meeting for the case tracked service user were not available for inspection. Two files contained a background history of the service user’s life from before they lived at the home. Due to the parents’ close involvement with the case tracked service user there was no background history on the third file, the Manager explained. The Senior Support Worker with Additional Responsibilities (SSWAR), who was spoken to, gave examples of service users making decisions and choices with staff assistance. She pointed out that just two options/alternatives are frequently offered to service users – more would be confusing for them, she explained. Good use was being made of symbols around the Home, to enable service users to communicate their wishes. Service users’ files contained a range of recorded risk assessments and many of these contained a section headed, ‘What are the benefits from taking the risk?’ This showed that staff were being encouraged to support service users to take responsible risks. The SSWAR confirmed this by reflecting on how one service user is supported in swimming and described the potential risks involved in this activity for this particular service user but also noted how fulfilling it was. Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 11 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 good. This judgement has been made using available evidence including a visit to this service. Service users were involved in fulfilling and age-appropriate activities within the Home and in the local community. They were able to maintain appropriate family relationships and peer friendships. Service users were provided with a healthy personalised diet. Daily routines reflected their individual choice and promoted independence. EVIDENCE: Each service user was being provided with a five-days-a-week day service. Two service users were receiving day services from Social Services and the Manager spoke positively about improved communication from the Day Centre. The case tracked service user was receiving a day service from United Response - mainly based at the Home. This service user had also recently started attending a drama group once a week – a move prompted by staff noting his enjoyment of a similar activity elsewhere in the week. The Manager gave other examples of staff listening to and observing service users’ behaviour in order to find ways of enhancing their quality of life. Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 12 The SSWAR spoke about a number of local facilities used by the service users. These included local shops, the pub and 10-pin bowling. She added that there were plans to introduce one service user to a local church. Also, there was an increasing social network, between this Home and the other two adjacent care homes, that benefits the service users and the staff, the Manager said. She added that a Christmas party at a local pub is planned in December for all three care homes. Each service user had been provided with a week’s holiday during 2006 – accompanied by two staff. A ‘photo-board’ on the dining room wall provided evidence of service users’ enjoyment. Other aspects of Standard 14 were not assessed. The Manager said that there was good involvement, from parents, with each of the three service users. For instance, the case tracked service user has contact with mother weekly and sometimes spends overnight at home. The SSWAR showed sensitivity and insight when speaking of family interaction during another service user’s trips home. The Manager spoke of a friendship having developed over seven years between another service user and an escort on day services transport. They have eaten out, together with staff, and the friend has acted as an advocate at Day Services. Two service users, who used to live at Morley Manor, were still friends with ex-staff from that establishment, the Manager said. Finally, the Manager spoke of a friendship between one service user and another from one of the other two care homes locally. They have had tea together and also spend time together on outside activities. The SSWAR considered that the bath-time routine promotes service users’ independence. She described the degree of self help achieved by one service user during this routine. This service user also enjoys the Home’s laundry routine, the Manager said - putting dirty clothes in a wash basket, then into the washing machine, then into the dryer and, finally, away in bedroom drawers. During this inspection staff were seen to interact positively with service users and not exclusively with each other. Food stocks in the kitchen were satisfactory and included fresh fruit and vegetables. Service users’ food preferences were recorded on file. The Home’s menu showed that service users were being provided with a nutritious and balanced diet. The Manager said that all service users were involved in food shopping and in clearing up after a meal. One service user particularly enjoyed food shopping, food preparation and laying the dining table, the Manager said. Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence including a visit to this service. Service users were receiving personal support in the way they preferred. Their health needs were being met although they were not always being protected by the Home’s procedures for dealing with medicines. EVIDENCE: The Manager said that the case tracked service user goes to bed late and gets up early each morning – his choice, she explained. The SSWAR said that routines were flexible to reflect service users’ needs. She gave an example of one service user making a very definite decision about changing the routine of what to wear, while on holiday. The SSWAR also spoke about ways that staff support and encourage service users’ privacy during personal care tasks, and their dignity through measures such as tucking in clothing after they have dressed. It was noted that service users’ likes and dislikes were recorded on their ‘Personal Profile’. There was also recorded evidence of Makaton symbols being used, in a variety of ways, to increase service users’ independence. Individual service users’ files contained health related records such as weight charts and bath temperatures. Health appointments were being recorded on separate A4 sheets that included space for information about the reason for the appointment as well as information from the appointment. Other health Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 14 related incidents, such as nose bleeds, were also being recorded on these sheets and were signed and dated. The case tracked service user’s file provided evidence of involvement from a range of health professionals. Evidence of service users’ health needs being met imaginatively took the form of an air-conditioning unit being provided in the bedroom of one service user, with epilepsy, to reduce the incidents of seizures during this Summer’s warm nights. Service users medicines were being stored securely. The case tracked service user’s Medication Administration Record (MAR) chart was examined. There was no recorded evidence of medication having been administered on the morning of 12 November although the Manager explained that the member of staff had told her the dose had been administered. As at the previous inspection, there was no signature, date or counter-signature beside handwritten entries, on another MAR chart, reflecting changes to doses. Also, there was still no ‘signature sheet’ available showing staff names and sample signatures/initials so it was not always clear whether an entry on the medication records was staff initials or a code. United Response’s Medication Procedures, dated 12 March 2004, were examined but they did not make any reference to expected practice regarding handwritten entries on medicine charts or on administration of medicines straight from the original container, for example. Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 15 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. This judgement has been made using available evidence including a visit to this service. Service users were benefiting from the Home’s complaints policy and procedures. They were being protected from abuse. EVIDENCE: The displayed complaints procedure made good use of widgets (symbols) that service users could more easily understand than the written word. Although this copy made reference to the Commission for Social Care Inspection the complaints procedure within the service users’ guide still referred to the National Care Standards Commission, which no longer exists. Staff had access to a comprehensive and constructive set of written complaints procedures entitled, ‘Comments, concerns and complaints’. The Manager confirmed that there had been no complaints about the Home received within the previous 12 months. The previous concerns expressed by neighbours, about the level of noise from at least one of the service users, had been dealt with in a constructive way and the Manager said the Home was on better terms with neighbours now. She said she had monthly talks with a spokesman for the neighbours. The Manager, SSWAR and one senior support worker had received training by Derbyshire Social Services in Safeguarding Adults (adult abuse) matters. All staff had attended United Response training on Safeguarding Adults. The United Response Policy & Procedure on Safeguarding Adults, and Whistle Blowing policy, were examined and found to be satisfactory. The SSWAR showed a good understanding of these policies. The pre-inspection questionnaire showed that no staff had been referred for inclusion on the government’s Protection Of Vulnerable Adults (POVA) list. Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. Service users were living in a comfortable and safe environment that was clean and hygienic. EVIDENCE: The kitchen had a new cooker and was newly refurbished and the lounge had been recently re-decorated. The floor covering in the upstairs toilet had been replaced although there was damage to the painted wooden boxing in this room. Each of the service users’ bedroom doors had a suitable lock although none of the service users would be able to hold their own door key, the Manager said. She also felt that no service user would understand the need for locked space in their bedrooms. Reasons for not providing this facility had not been recorded on care plans. The Home had a more homely appearance than at the last inspection and there was a discussion with the Manager over the benefits of further improvements such as more wall pictures in the lounge, a light shade in the ground floor toilet and blinds/curtains in some rooms where there were none. There was an attractive rear garden. The Home was clean and hygienic and there were no unpleasant odours. The SSWAR described good practice regarding the transfer of infected materials Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 17 within the Home. No communal rooms have to be passed through by staff between bedrooms and the laundry room. It was noted that there was a sluicing cycle on the washing machine. There was still no written policy & procedure on continence promotion – this was relevant to one service user. Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. Service users were being supported by a well-trained staff group and protected by the Home’s recruitment procedures. EVIDENCE: 50 of the staff group had a National Vocational Qualification (NVQ) at level 2 or above – an improvement on the last inspection. The Manager said there were no longer any staff vacancies and that a pool of peripatetic staff covered staff sickness and annual leave. Other aspects of Standard 33 were not assessed. Documents relating to the most recently appointed member of staff were examined. These met most of the legal requirements regarding the recruitment of staff. However, there was no photograph of the staff member on file and no evidence that a Criminal Records Bureau (CRB) disclosure had been applied for and received. In view of the usually good recruitment practices followed by United Response the Inspector accepted the Manager’s opinion that these items had been in place and had become missing. Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 19 There was evidence of this same member of staff being provided with induction training to Learning Disability Award Framework (LDAF) standards, as recommended by Standard 35. Training records were-up-to-date and showed that all staff had been provided with all mandatory training. Staff had individual training and development programmes that were an explicit part of the staff supervision process, the Manager said. The SSWAR spoke about training she had received within the previous 12 months. She had found a two-day Social Services course on ‘Person-Centred Planning’ to be particularly useful, saying, “It helped me to consider things from the service users’ perspective” and prompted asking the question, about an activity, “Is it a fulfilling activity for this service user?”. Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 20 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 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users were benefiting from a well run home and their health and safety was being promoted. They were not benefiting from an effective quality assurance system, where views of service users and other stakeholders were taken account of. EVIDENCE: The Manager had achieved a NVQ in Care and Management at level 4 and had been in this post for three years. She had worked with people with learning disabilities for 19 years. She spoke of being involved in United Response’s Leadership Management Development Programme – comprising monthly conference calls. There was evidence of an open and positive atmosphere within the Home. The SSWAR was enthusiastic and committed to her work and she spoke sensitively Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 21 about staff/service user interactions. Staff were observed to relate positively with service users. Monthly independent audit visits to the Home on behalf of the Registered Provider, as required by Regulation 26, were not taking place. The Manager said that the last monthly audit was in July 2006 and that United Response was only planning an independent audit every year. There were still no quality assurance questionnaires use, in order to assess opinions on the quality of service provided by the Home. There was discussion with the Manager on potential target groups to whom questionnaires could be sent: staff, relatives, external professionals and service users (with the help of independent advocates). The pre-inspection questionnaire, completed by the Manager, indicated that equipment in the Home was being maintained and good Health and Safety practices followed. However, the Home’s five-year Electrical Wiring Certificate was dated November 2000 and was therefore just out of date. The Manager was aware of this and had already arranged for an electrician to visit. Cleaning materials were being stored safely with Product Information Sheets in place, as required by the Control Of Substances Hazardous to Health (COSHH) Regulations. Fire alarm tests were being carried out weekly. Good food hygiene practices were being followed. Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 22 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 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 3 2 X X 3 X Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 23 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(2b) Requirement Service users care plans must be holistic and reflect the full range of service users’ needs. (This was a previous requirement). Staff must record all medicines administered. Monthly independent audit visits to the Home on behalf of the Registered Provider, as required by Regulation 26, must take place. The registered person must formally seek the views of service users, family, friends and others involved in the service users’ lives regarding the quality of service provided. (This was a previous recommendation) Timescale for action 01/03/07 2. 3. YA20 YA39 13(2) 26 01/01/07 01/01/07 4. YA39 24(1) 01/03/07 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 Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 24 1. 2. 3. YA1 YA6 YA20 4. 5. 6. 7. 8. YA20 YA20 YA22 YA24 YA24 9. 10. 11. 12. YA24 YA30 YA34 YA42 The Company should ensure that the Homes statement of purpose and service users guide are fully individualised to the Home. (This was a previous requirement). Service users’ care plan review minutes should be maintained at the Home for inspection at any time. (This was a previous requirement). Staff should be given access to written requirements and guidance such as the Medicines Act 1968 and guidelines from the Royal Pharmaceutical Society of Great Britain. The Other People to Contact sheet, accompanying the service users version of the complaints procedure, must make reference to the Commission for Social Care Inspection. (Previous timescale was 01/12/05). Handwritten entries on the Medication Administration Record sheets should be signed, countersigned and dated. (This was a previous requirement). ‘Signature sheets’ should be provided showing the names of staff who administer medication and their sample signatures/initials. (This was a previous recommendation) The complaints procedure, within the service users guide, should make reference to the Commission for Social Care Inspection. (This was a previous requirement). The painted wooden boxing in the upstairs toilet should be refurbished. Service users should be provided with lockable space in their bedroom or the reason for not providing this facility should be recorded on their care plan. (This was a previous recommendation) Improvements to the environment, detailed in this Standard, should be carried out. A written policy & procedure on continence promotion should be developed. (This was a previous recommendation) All documents required by Regulation to be in place prior to staff appointment should be maintained at the Home at all times. The Home’s five-year Electrical Wiring Certificate should be renewed. Blunt Street (7) DS0000019941.V319536.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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