Inspection on 15/01/08 for 7 Debdale Road

This inspection was carried out on 15th January 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

7 Debdale Road 08/01/09

7 Debdale Road 23/07/07

7 Debdale Road 11/07/06

7 Debdale Road 25/01/06

7 Debdale Road 20/04/05

7 Debdale Road 18/10/04

7 Debdale Road 07/05/04

7 Debdale Road 17/02/04

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 7 Debdale Road Wellingborough Northants NN8 5AA Lead Inspector Irene Miller Unannounced Inspection 15th January 2008 14.10 7 Debdale Road DS0000012762.V355118.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 7 Debdale Road DS0000012762.V355118.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. 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 7 Debdale Road Address Wellingborough Northants NN8 5AA 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) 01933 276930 01933 229606 www.caremanagementgroup.com Care Management Group Ltd (trading as CMG Homes Ltd) Mrs Hilary Jennifer Watt Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. By Agreement there is 1 Service user who has a mental disorder. No further service users are to be admitted in this category. By agreement there is 1 service user who has learning disabilities over 65 years. No further service users are to be admitted in this category. 23rd July 2007 Date of last inspection Brief Description of the Service: 7 Debdale Road provides care for up to five adults with a learning disability. The home is situated close to Wellingborough town centre and is in close proximity to all local amenities with good transport links both by bus and train into central Northampton. The home is a semi-detached house in a residential street with a large rear garden. All current residents are accommodated in single rooms. Previously there were two residents who shared a bedroom. Communal areas consist of a lounge and a dining room. The current fees range from £ 564 to £795 per week. All residents receive funding from Social Service Departments. There are costs for extras - hairdressing, toiletries, holidays, etc. The home’s Statement of Purpose and last Inspection Report are available on request. The service users guide is provided to residents and is on their files. 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is based upon outcomes for people living at the home and their views of the service provided. This visit was unannounced and focused on the ‘key standards’ under the National Minimum Standards and the Care Standards Act 2000 for homes providing care for younger adults (18-65) years. The care needs of two people living at the home were looked at in depth this involved looking through written information available on their care, such as their care plans (a care plan sets out how the home aims to meet the individuals personal, healthcare, social and spiritual needs). Time was spent with the people living in the home, during which time the views on the quality of care of the residents were sought and discussion took place with the residents and staff that were present. In addition observations of staff and residents interactions were made with an aim to establish how residents were supported. Sample checks were carried out on the homes policies and procedures and records in relation to staff recruitment, complaints, and general maintenance and upkeep of the facility were viewed. During the visit the residents and staff were given the choice of completing a satisfaction survey produced by the Commission for Social Care Inspection called ‘have your say’ the aim of completing the survey is to assess the level of satisfaction about the quality of the service that Debdale Road provides for those living and working at the home. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. What the service does well: Observation made during the visit indicated that the residents the staff appeared comfortable in each other’s company. There was laughter and a lighthearted atmosphere within the home. The staff were seen to care for the residents with respect and promoted their right to make choices and make their own decisions. 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 6 The staff turnover is low and this ensures that the residents are supported by staff that are fully aware of their individual needs and abilities. The home operates a flexible approach, and supports each resident to be as independent as possible. The care plans and risk assessments provide sufficient detail to inform the staff on the level of support required by each resident living at the home. What has improved since the last inspection? What they could do better: The property is in need of maintenance work to ensure that it remains safe and fit for purpose, the areas identified for urgent attention are: • • The damp to walls on the ground floor, there was a smell of damp, and flaking plaster was evident on the walls of the dining room, hallway and laundry. The large crack and dampness to the wall of the ground floor toilet Repairs and refurbishments to residents bedrooms must be done swiftly, one of the resident had been waiting for a bed to be removed from their bedroom for over six months (the bed had been left by the previous occupant) In addition the resident was unable to close their curtains (one curtain was hanging down and another window did not have a curtain in place). Privacy was not possible as the houses opposite overlook the bedroom. There was a vanity cabinet and sink in the bedroom that did not ‘fit’ the space of the old unit, the previous tiles had been removed and new tiling needed to be fixed on the wall around the sink unit. 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 7 Break downs of domestic equipment needs to be addressed in a timely manner the tumble dryer and dishwasher were out of order and in need of either repair or replacement. There must be a planned maintenance and renewal programme for the fabric and decoration of the home, with records kept. It was noted that the access to the laundry room is through the kitchen, and that this poses a cross contamination risk. There was no risk assessment in place to identify the control measures needed to reduce the cross contamination risk to an acceptable level. To reduce the risk of residents being harmed from hot surface temperatures risk assessments must be carried out on all the radiators, based upon the capability and vulnerability of risk to service users. All radiators identified, as high risk must have protective covers put in place. The afternoon/evening staffing levels need to ensure that support is available for residents to pursue their own interests and receive the level of support they require, should they wish to go out. 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. 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is good. The assessment process identifies the needs and aspirations of people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No new residents have moved into the home since the last inspection visit. The resident’s physical and emotional needs had been identified within their care plans, and there were records of the residents being fully involved in their care reviews. There were records available to demonstrate that health and social care professionals had been involved in the needs assessments. 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 & 9 Quality in this outcome area is good. The individual needs and choices of people living in the home are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents said that they did not feel restricted in any way and said that they were able to choose what they wanted to do such as going out, getting up and going to bed, they said that they could choose what to do in their leisure time and talked of visiting the local shops and going out with their keyworker. The staff confirmed that the home operates a flexible approach in supporting the residents, saying that each resident pursues their own individual daily and weekly routines, some attend work, and others attend day centres, the residents said that they enjoying a day off to do their shopping or to follow their own leisure pursuits and hobbies. 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 11 In discussion with the staff and residents it was confirmed that residents meetings take place on a regular basis, and the minutes of the meetings viewed showed that the homes complaints procedure and menus had recently been discussed with the residents. The care plans contained sufficient detail to inform the staff on the level of support required by each resident, and the care plans contained the details of the individual likes and dislikes of the residents in terms of their personal, social and cultural preferences. The risk assessments viewed addressed the hazards that present through the activities chosen by the residents. These included safety in the community, household tasks such as cooking and cleaning and managing personal finances. In discussion with the staff it was evident that they know the residents very well, and feel competent to provide the correct level of support for each person living at the home. The residents are encouraged to attend to their personal care as much as possible and take it in turns to help with cooking, one resident was observed to be helping to prepare Cottage Pie for the evening meal with the support of a staff member. Observation made during the visit indicated that there was good relationships between the staff and resident, there was laughter and the residents the staff appeared comfortable in each others company. The staff were seen to treat the residents with respect and promoted their right to make choices and make their own decisions. 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 & 17 Quality in this outcome area is good. The home supports the people living at the home to lead fulfilling lifestyles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was information contained within the care plans on the daily life choices of residents. The resident’s spoke of attending their day centres, saying that they liked meeting up with their friends and taking part in the activities there. One resident said that they enjoy going out to work and that they liked being independent, they talked of meeting up with friends at the local pub and going shopping independently. 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 13 The manager confirmed that the menus were being reviewed and that the residents were taking an active part in selecting what meal are to be included on the menus, and this was confirmed verbally by the residents and supported in the minutes of the latest residents meeting. There was a large bowl of fresh fruit available for residents within the kitchen, and snacks were available. The residents are encouraged to each take a turn in preparing the evening meals, and risk assessments were in place to support this activity. On the evening of the visit a resident was helping to make Cottage Pie. The residents spoke of going to Greece for their main holiday and in discussion with the staff and residents they confirmed that in addition to this main holiday that they go on long weekend breaks throughout the year. The minutes of the residents meetings demonstrated that the residents had been consulted about where to go on their main holiday and short breaks. The Annual Quality Assurance Assessment stated that the service has requested a bigger vehicle from the company as a result of residents saying it is not comfortable enough for them when full. 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 & 20 Quality in this outcome area is good. Residents receive good personal support with their physical and emotional health needs being met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were records available to support that the physical and psychological needs of the residents are met, such as attending appointments to see the GP, dentist, optician, chiropodist, district nurse, and community psychiatric nurse. There were records available on the resident’s health being monitored, such as records of weight, diet and nutritional needs being identified and healthy eating plans being in place where needed. The home has a policy and procedure for the safe administration of medications. The medication storage and administration records (MAR) sheets were sample checked and found to be all in order. 7 Debdale Road DS0000012762.V355118.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): Standards 22 & 23 Quality in this outcome area is good. The people living at the home are supported in making a complaint if they are dissatisfied with the service provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents said that if they were worried about anything they would speak to the staff or the Manager and they said that they were sure their concerns would be listened to. The Commission for Social Care Inspection has received no complaints since the last inspection visit. A resident said that they had been asking on numerous occasions for a bed to be removed from their bedroom and new curtains to be put up. This was causing some degree of anxiety for the resident and on speaking with the staff they confirmed that this request had been ongoing. The resident was asked if they would like to complain about their request not being addressed, they said that they had spoken with their keyworker, on speaking with the keyworker they said that they had passed the information onto the manager verbally. It is important that such requests are logged within 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 16 the concerns/ complaints record to ensure that matters are followed up in a timely manner. A member of staff was asked about their understanding on the safeguarding adult’s, policy and procedures and demonstrated that they had an awareness of human rights and the residents rights to treated with respect and dignity. In discussion with the manager and staff it was confirmed that abuse awareness training had been provided, however it is recommended that a training plan be put in place to identify when abuse awareness training updates are required, to ensure that the company abuse policy works in conjunction with the Northampton County Council Safeguarding Adults Policies and Procedures. 7 Debdale Road DS0000012762.V355118.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): Standards 24, 25, 26, 29 & 30 Quality in this outcome area is poor. Failure to carry out essential maintenance works and to address the needs and wishes of the people living at the home in terms of their privacy and individual lifestyles places the environment at risk of not being fit for purpose. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Areas identified for improvement during the previous inspection had not been addressed, within one residents bedroom the following areas for improvement still remained outstanding: • • The resident was still awaiting a bed to be removed from their bedroom that had been left by the previous occupant The resident was still awaiting curtains to be hung at their windows. The resident was unable to close their curtains (one curtain was hanging down and another window did not have a curtain in place). The houses opposite overlook the bedroom. DS0000012762.V355118.R01.S.doc Version 5.2 Page 18 7 Debdale Road • There was a vanity cabinet and sink in the bedroom that did not ‘fit’ the space of the old unit, the previous tiles had been removed and new tiling needed to be fixed on the wall around the sink unit. On speaking with the individual resident they seemed anxious that as the bed had not been removed, they may have to share her bedroom again, and said that they did not want to share their bedroom again. The resident said that they wanted their bedroom redecorated and some pictures hanging on the walls. The resident said that they had asked for curtains to be put up at their window and said they wanted the bed removed so that they could have a computer, and a computer desk and chair in their bedroom. They said that they liked to spend time in their bedroom doing jigsaws and watching TV. It was noted that there was no armchair within the bedroom, which left only the bed or the floor to sit on. The resident said that they had asked on many occasions for these areas to be addressed and this was supported by their keyworker. Many of the environmental areas for improvement identified during the last inspection still remained outstanding such as: • The damp problems to walls on the ground floor, there was a smell of damp, and flaking plaster was evident on the walls of the dining room, hallway and laundry. • Rotting skirting boards • A large crack and dampness to the wall of the ground floor toilet The laundry area to the rear of the kitchen was clean, however the tumble dryer was out of order, staff said that this had been reported to the manager and was to be either repaired or replaced under a maintenance contract. It was noted that the access to the laundry room is through the kitchen, when asked about the risk of cross contamination, the staff said that they ensure that bedding and clothing is carried through the kitchen in a sealed bag. However there was no risk assessment in place to review the cross infection procedures for this activity. The kitchen was viewed which was clean and records were available of food safety checks having been carried out. The dishwasher was out of order, the staff said that this had been reported to the manager and was awaiting either repair or replacement under a maintenance contract. Some new carpets had been fitted within the home and new flooring had been laid to the kitchen floor. The communal areas looked comfortable and clean, within the front lounge one of the residents who had limited mobility had bought their own reclining chair and they had also obtained and electric scooter to help in maintaining their independence. 7 Debdale Road DS0000012762.V355118.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): Standards 32, 33, 34 & 35 Quality in this outcome area is good. The staffing levels need to be consistent to meet all of the resident’s physical and emotional needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the afternoon/evening of the visit there was two staff to support four residents, and based upon the dependency level of the residents there was sufficient staff on duty to meet their needs. However on checking the staff rota it was apparent that this level of staffing in the afternoon/evening is not consistent. There were a number of occasions where there had been one member of staff on duty to support four service users during the weekend/evening periods when all the residents are in the home. In discussion with the staff and residents it was explained that this means that residents cannot go out when they want to or when a resident needs one to one support from staff then other residents cannot be given attention. 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 20 The Manager said that one to one support had been arranged for two residents for two days during the week. That one member of staff was on maternity leave and that a staff recruitment advertisement had gone out to temporarily fill this position, and that there was another staff vacancy to be filled. There is a sleeping staff member on duty at night with staff on call if needed. Staff recruitment records were sample checked and found to be in order with records of the new staff members having obtained clearance through the Criminal Records Bureau (CRB) and the necessary pre employment checks having been carried out. The staffs said that the manager supported them and that they receive one to one supervision. They had a sound knowledge of the needs of all the residents needs, and said ‘Rather than use agency staff, its much better to work an extra shift to ensure that the residents received the care and support that they need’. The Manager stated that all of the staff have a National Vocational Qualification (NVQ) level 2 qualification, as a minimum, and the staff spoken with said they were encouraged to undertake this training. One member of staff was looking forward to starting their NVQ 3 qualification. The manager confirmed that staff training had taken place in a range of areas, and consideration needs to be given to set up a matrix to identify when refresher training is next due. 7 Debdale Road DS0000012762.V355118.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): Standards 37, 39 & 42 Quality in this outcome area is adequate. Failure to act upon all of the requirements set by the Commission for Social Care Inspection places the homes registration at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager took up post in August 2007 and is yet to submit their application to be registered with The Commission for Social Care Inspection and is now urged to proceed with their application as a matter of urgency. Steps had taken place to address the requirements set following the last inspection visit, improvements had taken place in staff training, supervision and support. 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 22 However the property maintenance and repairs identified for improvement during the previous inspection had not been addressed, areas as identified under the ‘Environment’ section of this report remain outstanding from the last inspection. Residents said that they were happy living at the home and that they knew whom to speak to if they were unhappy about anything, however one resident who had made repeated requests for their bedroom to have curtains up at the windows, her room to be redecorated, and for a bed that was no longer in use to be removed, had found that her requests were not being addressed. The staff supported this view, saying that they too had raised concerns about maintenance and repairs to the home saying ‘that it appears that they are listened to by the company but no further action seems to be taken’. This was main cause of frustration for the staff. Staff said that the manager is supportive and said they were pleased that they are now receiving one to one supervision with the manager, that it gave the opportunity to bring up any concerns they may have directly with the manager and the opportunity to look at their training and development needs. The fire records showed that regular testing of emergency lighting was in place and that fire drills take place. The manager confirmed verbally that she was due to review the fire risk assessment. All of the radiators within the house had thermostatic control valves fitted, the company should carry out risk assessments on all of the residents in relation to their individual physical and psychological needs to identify were radiators may pose a high risk, such as bathrooms and individual bedrooms. In areas identified, as high-risk protective covers should be fitted to minimise the risk of a residents being harmed should they fall against a hot radiator. The manager confirmed that she has been obtaining quotes for the fitting of radiator covers. 7 Debdale Road DS0000012762.V355118.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 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 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 3 X 3 X 2 X X 2 X 7 Debdale Road DS0000012762.V355118.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 YA24 Regulation 23 (2) (b) Requirement The walls in the dining room and downstairs toilet must be attended to. The tumble dryer and dishwasher must be either repaired or replaced. There must be a planned maintenance and renewal programme for the fabric and decoration of the home, with records kept. In the bedroom identified the spare bed must be removed and curtains must be put up at the windows. There must be sufficient staff on duty in the evening and weekends to ensure that service users can pursue their own interests and receive the level of support they require. Risk assessments must be carried out on all radiators, based upon the capability and vulnerability of risk to service users. All radiators identified, as high risk must have protective covers put in place. Timescale for action 31/01/08 2 3 YA24 YA24 23 (2) (c) 23 (2) (b) 31/01/08 31/03/08 4 YA26 16 (2) (c) 31/01/08 5 YA33 18 (1) (a) 31/01/08 6 YA42 13 (4) 31/03/08 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 25 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 YA17 Good Practice Recommendations The review of the menus should continue to ensure that the residents are fully consulted on the selection of meals available. To ensure that the staff keep up to date with current care practices within the required time-scales. There should be a training plan in place to identify when staff are required to attend refresher training. 2 YA32 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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 7 Debdale Road DS0000012762.V355118.R01.S.doc Version 5.2 Page 27 - 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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