Inspection on 07/11/07 for 7 Blunt Street

This inspection was carried out on 7th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 7 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 14/11/06

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 Unannounced Inspection 7th November 2007 09:20 Blunt Street (7) DS0000019941.V352296.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.V352296.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.V352296.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) Blunt.Street8@unitedresponse.org.uk None United Response Christine Coates Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Blunt Street (7) DS0000019941.V352296.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 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. Blunt Street (7) DS0000019941.V352296.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 8 hours and was a key unannounced inspection. The Manager, the Senior Support Worker with Additional Responsibilities (SSWAR), and a support worker were spoken to. 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. Records were inspected and there was a tour of the building. One service user was case tracked so as to determine the quality of service from their perspective. Survey forms were posted to the relatives of the three service users – three were completed and returned; to six staff – two were completed and returned; and one health professional and two care managers – none were returned. The information supplied in this way was analysed before the inspection and the outcomes included in the inspection process and reflected in this report. 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, Annual Quality Assurance Assessment (AQAA), questionnaire was reviewed prior to this inspection. The Manager stated that the Home’s fees ranged from £1495 to £1800 per week. A copy of the last inspection report, from the Commission for Social Care Inspection (CSCI), is available to service users and visitors in the office. What the service does well: What has improved since the last inspection? New bedroom furniture had been purchased for one service user and there was new flooring in the dining room. The upstairs WC also had new flooring and wall tiling. There were new lampshades and wall pictures in the lounge. Some blinds and curtains had been fitted where previously there had been none. The care planning system had improved. One of the four requirements, and six of the twelve recommendations, made at the last inspection had been carried out. Blunt Street (7) DS0000019941.V352296.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.V352296.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.V352296.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 adequate. This judgement has been made using available evidence including a visit to this service. Service users were not being provided with sufficient information about the Home in order for them, and their relatives, to make an informed decision about whether the service is right for them. EVIDENCE: The Home’s Service Users’ Charter and Individual Charter contained a mixture of text, symbols, pictures and photographs. However, they were still not fully individualised to the Home or the individuals living there. The Individual Charter was dated December 2002 and did not contain details of the amount of fees currently payable. The Manager said she was planning to improve the format of these documents so as to make them more understandable to the individual service users. 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.V352296.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 had individual and up to date plans of care which demonstrated that their health, personal and social care needs were being met. A ‘person centred’ approach was being taken to ensure that service users’ individual needs and wishes were focussed on. EVIDENCE: The Home had developed a new care planning system since the previous inspection. This comprised, for each service user, a ‘Personal Planning Book’ and ‘Person Centred Review’ document. These were holistic in nature and took a suitably person centred approach. The case tracked service user’s Personal Planning Book was examined – it contained text and pictures and included sections entitled ‘The ways I communicate’ and ‘Important people in my life’. The latter section included photographs of the person’s parents. The Person Centred Review included sections entitled ‘What’s working and what’s not working’ and ‘Action Plan’. The latter section had listed a number of appropriate goals including the provision of more one-to-one time and a ‘Finance Spending Plan’. These new documents were still in the early stages of Blunt Street (7) DS0000019941.V352296.R01.S.doc Version 5.2 Page 10 completion and there was discussion with the Manager over the need to incorporate into the Personal Planning Books some goals that might, initially, seem to be guidelines for staff to follow rather than goals chosen by the service user. It was accepted, for instance, that the way staff should speak to service users can be phrased in a person centred way. Reviews were being held at appropriate intervals and included suitable relevant people. However, it was noted that, although a representative from the Derbyshire Social Services care management team was invited to review meetings, none had attended for two years. The Manager explained how the case tracked service user enjoys clothes and the way these add to personal appearance. The person was said to have preferred colours and was encouraged, and able, to choose clothes to wear each day with staff providing some guidance with respect to clothing appropriate for the weather. The person chose to put away their own clothes and had a particular place for each item. Good use was being made of symbols around the Home, to enable service users to communicate their wishes. Service users’ files each contained a person centred and generic risk assessment newly developed from a previous range of risk assessments. There was discussion with the Manager about adding some additional risks in respect of the case tracked service user’s potential behaviour in the kitchen. These new documents still contained a section headed ‘What are the benefits from taking the risk?’ – an indication that staff were being encouraged to support service users to take responsible risks. The support worker spoken to confirmed this by reflecting on how she supports one service user differently to another in respect of safely using footpaths by roads. The SSWAR provided an example of good practice when she spoke of making a risk assessment ‘on the spot’ at the dentist with respect to the case tracked service user. There was evidence of the Home exploring a range of ways of addressing this service user’s needs. Blunt Street (7) DS0000019941.V352296.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. The Home provided activities and services that were age-appropriate and valued by service users and promoted their independence. EVIDENCE: Each service user was being provided with a day service, either from Derbyshire Social Services or United Response. The case tracked service user was attending a Social Services day centre four days a week with one ‘personal day’ spent with staff at the Home on a one to one basis. The Manager spoke of plans to develop opportunities for further education and voluntary work for service users. The support worker spoken to gave examples of service users taking part in activities that were valued by them and fulfilling. These ranged from playing an organ at First Movement in Matlock to working with a jigsaw at the Home. The Manager gave examples of staff listening to and observing service users’ behaviour in order to find ways of enhancing their quality of life. The case tracked service user had chosen a preferred holiday in Norfolk this year and had chosen the staff to go with. A cork-board in the dining room Blunt Street (7) DS0000019941.V352296.R01.S.doc Version 5.2 Page 12 displayed ‘Our Photo Wall’ comprising photographs of holidays taken in 2006 and of the three service users’ families. The support worker spoke about a number of local facilities used by the service users. These included local shops, the pub, cafes and restaurants. She added that there was a disco for people with learning disabilities that service users enjoyed attending. There was also an increasing social network, between this Home and the other two adjacent care homes, that benefits the service users and the staff. One relative who responded to the postal survey said the Home does well by “giving (the service user) a variety in their life eg. trips, dancing and cinema”. The Manager said that there was good involvement, from parents, with each of the three service users. The SSWAR showed sensitivity and insight when speaking of family interaction during a service user’s trips home. Two service users, who used to live at Morley Manor, were still friends with ex-staff from that establishment, the Manager said. 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. Another relative who responded to the postal survey said the Home “relates well to parents of service users”. The support worker considered that routines in the Home were flexible and took account of each service user’s behaviour and frame of mind. She described the case tracked service user’s routines around personal clothes and it was clear that these promoted the person’s independence. There was evidence at this inspection of individual service users’ needs and compatibilities being considered when deciding the makeup of the group to go out that day. A person centred approach had been taken when reviewing domestic routines – a meal time care plan took account of the potential for agitation with regard to where the case tracked service user ate meals in the Home. Care plans included ‘preferred routines’. Food stocks in the kitchen were good 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. The case tracked service user was said to use the kitchen, with staff help, to make a cup of tea and items such as pizzas. Blunt Street (7) DS0000019941.V352296.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 adequate. This judgement has been made using available evidence including a visit to this service. Poorly completed medication records mean that service users may not be given their medicine. This potentially puts service users at risk of harm. EVIDENCE: The SSWAR is the Home’s Makaton trainer and she described the support provided to service users through the use of Makaton sign language and the way this reinforces verbal messages and increases service users’ independence. She also produced envelopes that contained Makaton symbol cards. Some staff have had full Makaton training while others are using it to more limited degrees that reflect simple choices that service users are making. It was clear from discussion that routines in the Home were flexible to reflect service users’ needs. Staff were supporting and encouraging 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 being recorded. One relative who responded to the postal survey said, “The service does well in meeting the service users’ needs for physical care and emotional care”. Blunt Street (7) DS0000019941.V352296.R01.S.doc Version 5.2 Page 14 Individual service users’ files contained health related records such as weight charts and bath temperatures. Health appointments were being recorded on ‘Feedback Sheets’ that included space for information about the reason for the appointment as well as information from the appointment. The list of health appointments for the case tracked service user included dentist, optician, wellperson clinic and medication reviews with a consultant psychiatrist. Each service user had a ‘My Health File’ – a person centred booklet that was in the early stages of completion. The case tracked service user’s file provided evidence of involvement from a range of health professionals. There were plans to introduce a ‘In case of hospital admission’ document that would provide a comprehensive and person centred picture of each service user. Service users’ medicines were being stored securely in personal medicine cabinets in their bedrooms – a move that the Manager described as “more private and person centred”. She also pointed out that with individual cabinets the risk of errors had been reduced. Medication Administration Record (MAR) sheets were examined. There was no recorded evidence, by means of a staff signature on one MAR sheet, of medication being administered to a service user recently, on three separate occasions. A similar situation was found at the previous inspection. Also, four staff members had signed to confirm medication had been administered to this same service user, over a period of 2½ weeks, when it had not been administered – following a mistake made by staff when initially drawing up the MAR sheet. A ‘Serious Concern Letter’ was issued to the Provider on these two issues. A positive and constructive response to this letter was received. Records confirmed that all staff had received accredited training in the safe use of medicines. There was a ‘signature sheet’ available showing staff names and sample signatures/initials. A new Medicines Policy had been drawn up by the Manager and a copy was being kept in each of the three medicine cabinets. However, this Policy still did not make any reference to all major aspects of good practice – for example, regarding handwritten entries on medicine charts or the administration of medicines straight from the original container. Blunt Street (7) DS0000019941.V352296.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. Procedures for handling complaints and abuse were in place, ensuring that service users were fully protected. EVIDENCE: The complaints procedure was displayed in the office. It made good use of widgets (symbols) that service users could more easily understand than the written word although the Manager stated she was aiming to improve upon this format. The displayed complaints procedure was not up to date in its contents. It made reference to the Commission for Social Care Inspection but the complaints procedure within the case tracked service user’s Service Users’ Charter did not. 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. An informal complaints procedure was not in place and there was discussion with the Manager about the management benefits of recording ‘concerns’ displayed or expressed by service users or relatives. For instance, one relative who responded to the postal survey felt that not all concerns were fully dealt with. 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 satisfactory. A new Whistle Blowing policy was in place and the Manager said this had been discussed at a team meeting and at staff Blunt Street (7) DS0000019941.V352296.R01.S.doc Version 5.2 Page 16 supervision sessions. The support worker spoken to showed a good understanding of these policies. The pre-inspection, Annual Quality Assurance Assessment (AQAA), questionnaire showed that no staff had been referred for inclusion on the government’s Protection Of Vulnerable Adults (POVA) list. The Manager said that staff training in non-physical intervention was up to date. The case tracked service user’s personal money record was examined. This was satisfactory except that there was no recorded evidence of the regular checks the Manager said she makes. Blunt Street (7) DS0000019941.V352296.R01.S.doc Version 5.2 Page 17 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 safe, comfortable and hygienic environment. EVIDENCE: Bedrooms were equipped with visual stimuli according to the individual’s needs and one bedroom was particularly comfortable and personalised. All service users had a 4-foot bed to provide more comfort and safety in the event of a seizure. Each of the 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 still not been recorded on care plans. New bedroom furniture had been purchased for one service user and there was new flooring in the dining room. The upstairs WC also had new flooring and wall tiling. The Home was generally well decorated and furnished and there were new lampshades and wall pictures in the lounge. Blinds and curtains had been fitted where previously there had been none. There was still no light shade in the ground floor toilet. Repairs made in March Blunt Street (7) DS0000019941.V352296.R01.S.doc Version 5.2 Page 18 2007, to the wall beside one service user’s bedroom door frame, had not been finished by decoration. The Home was clean and hygienic and there were no unpleasant odours. The support worker described good practice regarding the transfer of infected materials within the Home. No communal rooms have to be passed through by staff between bedrooms and the laundry room. 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. All staff had been provided with infection control training. The Manager said she had not received a copy of the Department of Health’s ‘Infection Control Guidance for Care Homes’, June 2006, or its ‘Essential Steps to safe, clean care’ ‘Selfassessment tool for care home’. Blunt Street (7) DS0000019941.V352296.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. The Home’s level of staff training fell short of fully safeguarding the welfare of service users. EVIDENCE: 50 of the staff group had a National Vocational Qualification (NVQ) at level 2 or above and one other staff member was working towards this qualification. The Manager said that there were plans to provide this training for the remaining three staff in 2008. Documents relating to the most recently appointed member of staff were examined. These met all the legal requirements regarding the recruitment of staff. The Manager stated that service users were involved in staff recruitment in so far as she observes candidates interactions with them. She added that the three service users’ needs and wishes are embedded in the job specifications for new staff. There was good retention of staff: one person had left the Home within the previous 12 months. There was evidence of this same member of staff being provided with induction training to Skills for Care Common Induction Standards, as recommended by Blunt Street (7) DS0000019941.V352296.R01.S.doc Version 5.2 Page 20 Standard 35. Training records showed that all staff had been provided with mandatory training in Basic Food Hygiene and First Aid. However, three staff had not had recent Moving & Handling training and only one member of staff had had two fire training sessions within the previous 12 months. The support worker spoke about the training she had received and this included training on cultural needs. Blunt Street (7) DS0000019941.V352296.R01.S.doc Version 5.2 Page 21 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’ best interests were not being promoted by the systems in place and their health and safety could be compromised. EVIDENCE: The Manager had achieved a NVQ in Care and Management at level 4 and had been in this post for four years. She had worked with people with learning disabilities for 20 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 support worker spoken to described the Home’s atmosphere as being “friendly and relaxed, with approachable management”. Staff were observed to relate positively with service users. Blunt Street (7) DS0000019941.V352296.R01.S.doc Version 5.2 Page 22 The Manager stated she was undertaking quarterly checks of the Home as required by United Response. However, monthly independent audit visits to the Home on behalf of the Registered Provider, as required by Regulation 26, were still not taking place. This was due to unavailability of the Area Manager, the Manager said. Also, there were still no quality assurance questionnaires being sent out, in order to assess opinions on the quality of service provided by the Home. The Manager said there was a suitable questionnaire ready to send out. The Home’s 2005/6 Annual Plan was seen but, although the Manager said there was a current one, this was not available at the inspection. The AQAA indicated that equipment in the Home was being maintained except that the Home’s five-year Electrical Wiring Certificate was dated November 2000 and had not been renewed since this was pointed out at the previous inspection. The Manager stated that the landlord had been informed but had taken no action. Extractor fans in the first floor WC and the bathroom were dirty and not working. This was considered a potential fire risk. A ‘Serious Concern Letter’ was issued to the Provider on these two Health & Safety issues. A positive and constructive response to this letter was received. 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 drills were being carried out 6-monthly. Good food hygiene practices were being followed. A Health & Safety audit, undertaken by a United Response HR manager had reported that “I found a high standard of Health & Safety throughout the service”. Blunt Street (7) DS0000019941.V352296.R01.S.doc Version 5.2 Page 23 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 2 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 2 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 1 X 3 3 1 X X 1 X Blunt Street (7) DS0000019941.V352296.R01.S.doc Version 5.2 Page 24 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 Staff must accurately, and with consistency, record the medicines administered to service users. This is to ensure that service users have received their medicines as prescribed. (Previous timescale was 01/01/07). All staff who work night shifts must be provided with fire training twice a year to ensure the safety of service users is not compromised at night. Moving & Handling training must be provided for all staff that work with people who have been assessed as having difficulty in moving themselves. Monthly independent audit visits to the Home must take place, to ensure the Registered Provider is kept aware of the Home’s conduct. (Previous timescale was 01/01/07). The registered person must formally seek the views of service users, family, friends and others involved in the service users’ lives. This is to provide evidence of the quality of service DS0000019941.V352296.R01.S.doc Timescale for action 12/11/07 2. YA35 23(4)(d) 01/02/08 3. YA35 13(5) 01/02/08 4. YA39 26 01/01/08 5. YA39 24(1) 01/01/08 Blunt Street (7) Version 5.2 Page 25 6. YA42 23(4)(a) 7. YA42 23(4)(a) being provided. (Previous timescale was 01/03/07). An assessment of the nonworking extractor fans in the first floor bathroom and the toilet must be made by an electrician as these are considered a potential fire risk. An assessment of the electrical wiring of the premises must be made by an electrician and a new Electrical Wiring Certificate must be issued. 19/11/07 19/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The Company should ensure that the Homes Service Users’ Charter and Individual Charter are fully individualised to the Home, and to service users, and ensure that the Individual Charter includes details of the amount of fees currently payable. (This was a previous recommendation). The Manager and staff should continue to complete the new person centred care planning documents and incorporate into them goals that might, initially, seem to be guidelines for staff to follow. Risk assessments should be reviewed to ensure they refer to all matters that could potentially put service users and staff at risk. The Home’s medicine policy should make reference to all major aspects of good practice, as detailed in this report, and should be drawn from written guidance from the Royal Pharmaceutical Society of Great Britain. (This was a previous recommendation) The Home’s complaints procedure should be displayed in a prominent position. It should be updated. The complaints procedure, within the Service Users’ Charters, should make reference to the Commission for Social Care Inspection. (This was a previous recommendation). DS0000019941.V352296.R01.S.doc Version 5.2 Page 26 2. YA6 3. 4. YA9 YA20 5. 6. YA22 YA22 Blunt Street (7) 7. 8. 9. YA22 YA23 YA24 10. 11. YA24 YA30 12. YA42 An informal complaints/concerns procedure, with records, should be developed. The Manager should record evidence of periodic checks made to service users’ personal money records. 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). A copy of the Department of Health’s Infection Control documents, detailed in this report, should be obtained. The Home’s five-year Electrical Wiring Certificate should be renewed. Blunt Street (7) DS0000019941.V352296.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Blunt Street (7) DS0000019941.V352296.R01.S.doc Version 5.2 Page 28 - 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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