Inspection on 26/10/06 for 8 Queensview Crescent

This inspection was carried out on 26th October 2006.

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

Other inspections for this house

8 Queensview Crescent 18/03/09

8 Queensview Crescent 25/02/08

8 Queensview Crescent 09/03/05

8 Queensview Crescent 21/09/04

8 Queensview Crescent 03/03/04

8 Queensview Crescent 27/01/02

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

CARE HOME ADULTS 18-65 8 Queensview Crescent Warley Road Scunthorpe North Lincolnshire DN16 1QN Lead Inspector Ms Matun Wawryk Unannounced Inspection 26th October 2006 09:00 DS0000002871.V308598.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 DS0000002871.V308598.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. DS0000002871.V308598.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 8 Queensview Crescent Address Warley Road Scunthorpe North Lincolnshire DN16 1QN 01724 280862 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.dimensions-uk.org Dimensions (UK) Ltd Maria Powell Care Home 6 Category(ies) of Learning disability (6), Physical disability (3) registration, with number of places DS0000002871.V308598.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th August 2005 Brief Description of the Service: 8, Queens View Crescent is a care home providing personal care and accommodation for six adults aged 18-65 years with learning disabilities, three of these places are for service users who also have a physical disability. Queensview Crescent is owned by Dimensions (UK) Ltd and is situated close to two other homes owned by Dimensions The home is located in a residential area close to the centre of Scunthorpe. It is close to local shops, amenities and public transport. The home has it’s own transport. The home is a purpose built bungalow. All the service users have access to a single bedroom with a wash hand basin. Bedrooms are decorated and furnished to meet individual service users requirements and preferences. Communal areas of the home are decorated and furnished in a domestic style. Aids and adaptations are provided as required to meet service users needs. DS0000002871.V308598.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first key inspection of 2006/07. The inspection visit took place over 1 day in October 2006. Mrs Matun Wawryk, Regulation Inspector carried out the site visit. Prior to visiting the home the inspector sent out a selection of survey questionnaires to all the service users and staff and some professional staff. Comments received were analysed on their return and any issues identified were checked out during the inspection visit. Following the inspection visit questionnaires were also sent to all the service users relatives. Some of the comments received by people have been included in the report. Information received by the Commission since the last inspection was also considered in forming a judgement about the overall standards of care provided by the home. Four service users were at home on the day of the inspection visit. Most of the service users had very limited verbal communication skills; therefore the inspector spent time with service users observing activities instead of conducting formal interviews. The inspector also had discussions with the manager and two support workers who were working in the home at the time of the visit. The inspector checked to see that service users privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured service users were safe and protected in their environments. Documentation in relation to the assessments people had prior to the admission to the home and support plans produced to meet assessed needs were examined. In addition the inspector also looked at a number of records in relation to medication practices, complaints management, staffing levels, staff training, induction and supervision. The inspector also looked at how the home monitored the quality of the service it provided and how the home was managed overall. What the service does well: The home ensures service users and their carers received good and timely information about the home. This means prospective service users and their carers have access to sufficient information to enable them to make informed decisions about the homes capacity to meet their needs. DS0000002871.V308598.R01.S.doc Version 5.2 Page 6 Individual support plans for service users are comprehensive and reflect all areas of identified needs. This means staff have access to all necessary guidance to enable them to meet the needs of service users. Service users had good access to professional medical staff and were able to access external services such as dentists and opticians. The way staff were recruited was good. This means the home takes appropriate action to safeguard and protect service users from harm by operating safe recruitment practice. There remains a core group of staff that had worked in the agency for several years. This means service users generally receive care and support from staff they are familiar with. What has improved since the last inspection? What they could do better: The home was not regularly checking the temperature of the drugs cupboard. This should now happen, as it is important that medication is stored at the right temperature. On checking a sample of medication administration the inspector noted some transcribed medication had not been counter signed. In order to ensure proper safeguards are in place a second member of staff should witness all hand written annotations on Medication Administration Record charts. Management of controlled medication was satisfactory, but better storage needs to be provided. The manager must ensure all staff are provided with adult protection training. This is needed to ensure staff fully understand adult protection matters and to ensure they understand the local arrangements for reporting allegations or suspicions of adult abuse. The manager had not sat down with each member of staff to decide what training they needed. This is needed to ensure the homes training plans meet DS0000002871.V308598.R01.S.doc Version 5.2 Page 7 the training needs of staff; thereby ensuring staff are able to meet the changing needs of service users The home needs to put in place a better quality monitoring system. This is needed to make sure that everyone is consulted about the running of the home and to ensure continuous improvements are made. The home then needs to produce an annual report and make this available to people who use the service, their relatives and carers and other relevant people, including the Commission for Social Care Inspection. The inspector would like to thank everyone who completed a questionnaire and/or took the time to talk to her during this inspection. Your comments and input have been a valuable source of information, which has helped create this report. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000002871.V308598.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 DS0000002871.V308598.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): 1, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives were provided with sufficient information to help them decide if the home was right for them. The admission procedure was thorough thereby providing staff with sufficient guidance to ensure prospective service users needs are properly assessed and planned for. EVIDENCE: A statement of purpose and service user guide was available. The manager gave an assurance that a copy of the guide was issued to all service users on admission. The guide had been reproduced using symbols to improve its accessibility for service users. The admission procedure was adequate to guide staff on the actions to be taken to ensure that prospective service users needs are properly assessed and planned for. The manager stated that in the absence of a professional assessment she or one of the other managers would undertake a needs’ assessment of DS0000002871.V308598.R01.S.doc Version 5.2 Page 10 prospective service users. A pro-forma for recording assessments was available. Discussion with the manager indicates that the home obtain a copy of the care management assessment and care plan. The inspector case tracked one service user and records evidenced that the service user had had their needs assessed prior to admission to the home. During the visit the inspector spoke to the two support workers who were working in the home at the time of the visit, both workers were very knowledgeable about the care and support needs of the service users. One service user spoken to said they liked living in the home and described that staff as ‘good’. None of the other service users were able to tell the inspector about their care needs and the input they required from staff. Three relative surveys were returned; of these two indicated that they considered the level of care provided was good. One relative commented that there was insufficient staffing and that their relative did not have sufficient opportunity to go out. DS0000002871.V308598.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6. 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care and support each service user needs and receives is documented and care provided is based on assessment of individual needs and choices. EVIDENCE: Case tracking took place for two service users. The methodology used was a physical examination of care plans, written surveys to service users, staff, relatives and health and social care professionals, and direct observation on the day of the inspection visit. The home had made some progress in developing essential life plans; these now need to be completed for all the service users. DS0000002871.V308598.R01.S.doc Version 5.2 Page 12 Individual support plans were in place for the two service users selected for case tracking and these set out the health and personal care needs identified for each person. Plans looked at had been regularly evaluated and any changes to the care being given was documented and implemented by the staff. There were risk assessment tools for mobility, tissue viability, bed rail provision, medication, nutrition and general issues; all high risk areas identified had been reviewed and care plans were in place to support appropriate care provision. Work now needs to be completed on developing the support plans and risk assessments in more suitable formats for the service users as one means of improving the accessibility of these important documents for service users. Records evidenced regular care reviews were held with the responsible funding authority. DS0000002871.V308598.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to maintain links within the community. The routines of the home are flexible to meet individual service users needs. The meals provided to service users are of a good quality and offer variety and choice. EVIDENCE: The home does not employ an activity coordinator; support workers are responsible for organising and arranging activity programmes. Records did not evidence that staff had been provided with training in planning and delivering activity programmes for people with complex needs. The inspector advises that DS0000002871.V308598.R01.S.doc Version 5.2 Page 14 consideration should be given to providing staff with relevant training in this area. A formal activity programme was not available; staff reported that activities were planned on an individual basis. This included; hands massages and nail care, outings, pub visits and shopping trips. Although support plans for recreational and personal development were in place, in some cases these needed to be more detailed to better reflect recreational and personal development needs of the individual. One service user told the inspector that staff supported her to attend a weekly line dancing class. One relative commented via their survey questionnaire that their relative did not have sufficient opportunity to go out. The registered person must, on a regular basis, continue to consult service users about the programme of activities on offer in the home and ensure support plans reflect the individual preferences and capabilities of service users. Four of the service users attended day services provided by the local authority. One service user received time limited support from day centre staff in his home. Anecdotal evidence indicated some service users have had their day centre time reduced over the last two years. This matter needs to be kept under review to ensure service users social, recreational and personal development needs continue to be met in an appropriate manner. Discussion with staff indicated most service users had good contact with their families and friends. Staff stated relatives and visitors are made welcome at any reasonable time and comments received form three relatives confirmed this. Key workers helped service users to maintain family contact by sending cards at significant occasions such as birthdays and Christmas, thereby helping service users to maintain family contacts. The standard of the meal provision in the home was good. Service users were provided with three meals a day and records showed that a varied menu was available. Food likes and dislikes were recorded. The inspector spent time in the dining area observing the lunchtime meal. Staff were observed to assist service users to eat in a sensitive manner and service users were not hurried. Staff had a good knowledge of the service users food preferences, portion size and manner of eating. DS0000002871.V308598.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is offered in such a way as to promote and protect the service users privacy and dignity. Arrangements for meeting the health care needs of service users are generally satisfactory. Some improvement is needed in the way medication is stored and recorded. EVIDENCE: All the bedrooms are single occupation this means treatments and examinations can be carried out in private. Individual service user support plans describe how personal care should be provided to ensure the dignity and privacy of the service user is maintained and promoted. As the staff team was made up of both male and female carers choices could be accommodated. DS0000002871.V308598.R01.S.doc Version 5.2 Page 16 All service users were registered with a GP. A record of routine eye tests, dental and chiropody checks had been maintained and service user weights were being monitored, although not always at frequencies detailed in the service users individual plan. The manager should ensure this now happens. Records and discussion with staff demonstrated that the manager had requested GP’s to carry out annual health checks including a review of medication. Individual health action plans had not been introduced into the home. When questioned about this the manager reported that discussions were taking place with the local authority regarding this issue. The home uses the Nomad system for drug administration. The home did not have a drugs trolley; medication was being stored in a locked metal cupboard. The home was not regularly checking the temperature of the drugs cupboard. This should now happen, as it is important that medication is stored at the right temperature and where needed action should be taken to ensure medication is stored in line with guidance issued by the manufacturer. On checking a sample of medication administration records (MAR), no omissions or errors were noted, however some transcribed medication had not been counter signed. In order to ensure proper safeguards are in place a second member of staff should witness all hand written annotations on Medication Administration Record charts. One service user had been prescribed a controlled drug. Controlled drugs in use were stored in metal cupboard inside a second cupboard. An appropriate register was in use and administration and balances of medication were recorded in the register. The registered person must ensure that controlled medication is stored in a cabinet, which is secured to the wall with the required rag bolt as stated in the Misuse of Drugs (Safe Custody) Regulations 1973. Since the last inspection a programme of in-house medication training had been introduced and this included assessment of competence. Records and direct observation identified staff were carryout specialist tasks for example Percutaneous Endoscopic Gastrostomy (PEG) feeding. Records identified staff had had training, however this had not included assessment of competence. The registered person must include assessment of competence specific to the service user, by the community nurse or dietician (or a company trainer who they have asked to provide this training on their behalf) who assumes responsibility for delegating this task. DS0000002871.V308598.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a satisfactory complaints system and staff and service users can be assured complaints and concerns will be listened to and acted upon. Adult protection systems need to be supported by a staff-training programme. EVIDENCE: There have been no complaints made to the Commission or the home in the last twelve months. The home had a clear complaints procedure and the procedure was available in a suitable format for service users. Staff spoken said they had no complaints about the home and felt confident to raise issues of concern if they arose. None of the residents were able to confirm to the inspector their understanding of the complaints process, comments from returned relatives questionnaires indicates that relatives are aware of how to complaint. No adult protection referrals had been made in the last twelve months. A procedure for responding to allegations of abuse was available, which reflected the multi-agency procedures in respect of referral and investigation. Records indicated that only 50 of staff had had adult protection training. The need to DS0000002871.V308598.R01.S.doc Version 5.2 Page 18 ensure all staff are provided with adult protection training remains an outstanding requirement from previous inspections and action must now be taken to address this. DS0000002871.V308598.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with a warm and comfortable environment, however some carpets need replacing and work needs to be carried out in the garden to improve its accessibility for service users. EVIDENCE: A tour of the home was carried out and all areas were seen to be clean, tidy and odour free. Since the last inspection the lounge cum dinning room had been redecorated. All bedrooms looked at were clean and tidy and were furnished and decorated in a homely style. Many people had furnished their bedrooms with a range of DS0000002871.V308598.R01.S.doc Version 5.2 Page 20 personal items, some bringing in items of furniture to reflect their own individual choice and taste. One service user told the inspector that she ‘ liked her bedroom’. Observation of the premises showed that there are some minor areas still needing work; the lounge carpets and some service users bedroom carpets need replacing. Cleaning had failed to remove marks and stains. Whilst these matters do not pose any health and safety problems they do not ensure service users live in an attractive environment. The gardens remain largely inaccessible to service users due to problems with layout and design. This matter has been identified in inspection reports spanning the last fours years. During this time little or no work has been carried out to improve the attractiveness and accessibility of the garden and the manager confirmed that there are no plans to do so. This means service users do not have free access to all parts of their home. Action must be taken to address this. At this inspection visit the inspector noted that some parts of the perimeter fence was damaged and broken. Necessary repair work must be carried out to ensure the safety of service users and staff. Staff reported that they had access to all required specialist equipment needed to ensure service users needs could be met, this included a hoist, additional moving and handling and specialist bathing equipment. DS0000002871.V308598.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides sufficient numbers of staff on each shift to meet the care needs of service users; staff are trained and competent to carry out their duties and responsibilities EVIDENCE: The roles and responsibilities of staff are clearly defined and understood. Two support workers spoken to were able to fully describe the management and reporting arrangements in place in the home. Five service users were living in the home at the time of the inspection. Two support workers are normally on duty at anyone time. At night there is one waking and one sleep in worker on duty. DS0000002871.V308598.R01.S.doc Version 5.2 Page 22 At the last inspection visit staff commented that staffing levels did not enable quality time to be spent with some service users. At this inspection visit staff said staffing levels did now ensure service user needs were met in a satisfactory way. Three relatives returned a survey questionnaire, of these two indicated staffing levels were satisfactory; one stated staffing levels were unsatisfactory. A formal review of staffing based on assessment of the dependency levels of service users had not been carried out and the home did not have a formal dependency tool. Feedback from staff indicated that the dependency levels of some service users had increased over the years and anecdotal evidence indicates that day centre time for most service users has been reduced. The inspector advises that a formal review of staffing should be carried out using a recognised dependency tool, this will enable more informed judgements to be made about the number of care hours needed to meet the needs of service users. The inspector examined the personnel file for the one new worker employed since the last inspection. All records and checks required by Regulation 19 of the Care Homes Regulations were available. This means the homes takes appropriate steps to protect service users through sound recruitment and selection practice. The home had a structured induction programme in place, which the manager stated met the new Common Induction Standards of Skills for Care (formerly TOPPS) for new members of staff. One support worker had obtained a National Vocational Qualification (NVQ) at level 2 and another three others were in the process of completing an NVQ. The registered person must continue with the NVQ training programme to ensure 50 of care workers achieve an NVQ. A formal staff supervision programme was in place and records evidenced staff received formal recorded supervision. Since the last inspection there had been some slippage in the frequency of supervision for some staff. The manager must ensure staff are provided with a minimum of six supervision sessions per annum. A programme of annual appraisals for staff was in place, however the manager reported that these were not up to date for all staff. Steps must now be taken to address this. This is needed to ensure the homes training plan and priorities reflect the training and development needs of the staff team. DS0000002871.V308598.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was effectively managed. Efforts must now be made to formalise the quality assurance programme. EVIDENCE: The manager had considerable experience of managing the home and had enrolled to complete the registered manager award. The manager said that she keeps her skills up to date through attending regular training sessions relevant to her role. DS0000002871.V308598.R01.S.doc Version 5.2 Page 24 Staff spoken to and those who returned a questionnaire said the home was run in the best interests of service users. Staff confirmed that moral was good and staff said there was a good team approach to care delivery at the home. Evidence from staff interviews and staff surveys indicated the staff consider the manager to be approachable, staff said she takes issues raised seriously and takes prompt action to resolve matters. The home had a range of mechanisms in place to monitor the quality of services provided including regular audits of the homes environment, regulation 26 visits and reports, a staff survey questionnaire and individual service user reviews. However a specific development plan for the home and published report was not available. The registered person must implement a quality assurance programme, which fully meets the requirements of NMS 39. This is needed to make sure that everyone is consulted about the running of the home and to ensure continuous improvements are made. This remains an outstanding requirement from previous inspections and action must now be taken to address this. The home had a range of policies and procedures for health and safety. Safe working practices were maintained by the provision of training to staff in the form of moving and handling, basic food hygiene, first aid and health and safety. The provider information questionnaire states current certificates were in place for the gas, portable electrical appliances and fixed electrical systems. Accident records were completed appropriately and the manager carried out regular audit on these to help spot any problems or recurring themes. DS0000002871.V308598.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 2 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 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 2 X 2 X X X 3 DS0000002871.V308598.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA28 Regulation 23(2)(o) Requirement The registered person must ensure that the gardens are safe and accessible to all service users. Timescale of 16.10.03 31.11.05 and 31.03.06 not met Timescale for action 31/03/07 2. OP19 18(1)(c) 28/02/07 The registered person must ensure where training for PEG (Percutaneous Endoscopic Gastrostomy) feeding is provided this must include assessment of competence specific to the service user, by the community nurse or dietician (or a company trainer who they have asked to provide this training on their behalf) who assumes responsibility for delegating this task. The responsible person must develop support plans in a more accessible format for service users. Timescale of 31.3.05 and 31.11.05 and 31/03/06 not met. The registered person must develop a quality assurance and monitoring system that meets the requirements of this DS0000002871.V308598.R01.S.doc 3. OP6 12(3) 31/03/07 4. YA39 24 31/01/07 Version 5.2 Page 27 standard and produce an annual development plan based on a systematic cycle of planningaction-review, reflecting aims and outcomes for service users. Timescale of 19.2.04 and 31.12.05 and 30.4.06 not met 5. YA37 18 The registered manager must obtain an NVQ level 4 or equivalent. Timescale of 31.12.05 and 31.7.06 not met The registered person must have the sitting room replaced. The registered person must ensure staff are provided with adult abuse training. Timescale of 31.3.06 not met The registered person must ensure that controlled medication is stored in a cabinet, which is secured to the wall with the required rag bolt as stated in the Misuse of Drugs (Safe Custody) Regulations 1973. The registered person must have the perimeter fence repaired or replaced 31/03/07 7. 8. YA34 YA23 13 13 31/01/07 31/12/06 9 YA20 13 31/12/06 10 YA28 23(2)(o) 21/12/06 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 YA32 Good Practice Recommendations The registered person must ensure 50 of care staff achieve an NVQ. DS0000002871.V308598.R01.S.doc Version 5.2 Page 28 2 YA20 The registered person should ensure a second member of staff should witness all hand written annotations on Medication Administration Record charts. Medicines must be stored at the appropriate temperature. A record of temperature must be maintained for all areas where medicines are kept 3 YA20 DS0000002871.V308598.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000002871.V308598.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!