Inspection on 15/09/05 for 8 St Winifred`s Road

This inspection was carried out on 15th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 no outstanding requirements from the previous inspection report, but made 29 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

8 St Winifred`s Road 17/07/08

8 St Winifred`s Road 16/01/07

8 St Winifred`s Road 26/01/06

8 St Winifred`s Road 21/10/04

8 St Winifred`s Road 16/04/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 8 St Winifred`s Road Shirley Southampton Hampshire SO16 6HP Lead Inspector Christine Hemmens Unannounced Inspection 15th September 2005 10:00 DS0000011806.V249989.R01.S.doc Version 5.0 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 DS0000011806.V249989.R01.S.doc Version 5.0 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. DS0000011806.V249989.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 8 St Winifred`s Road Address Shirley Southampton Hampshire SO16 6HP 023 8070 5506 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) H4mo12tauarez@mencap.org.uk Royal Mencap (Housing & Support Services) Mrs Ann Marie Tavarez Care Home 8 Category(ies) of Learning disability (8) registration, with number of places DS0000011806.V249989.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st October 2004 Brief Description of the Service: 8 St Winifred’s is a large detached family home situated in a quiet cul-de-sac close to Shirley High Street and local amenities. The home is registered to accommodate 8 residents with learning disabilities between the ages of 18 – 65. The current residents are all over the age of 30. Hyde Housing Association owns the property and Mencap manage the services. The manager has recently been registered with the Commission for Social Care Inspection. The home comprises eight single bedrooms, which are spacious and suitably furnished. There is a lounge, lounge/dining room and large kitchen and the home has a rear garden for recreational use. DS0000011806.V249989.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first visit to the home this year and was carried out over one day. The deputy manager assisted the inspector with the visit as the registered manager was on a course for the day. The inspector met with four residents throughout the course of the day and spoke briefly with staff. The residents were observed to be involved in activities around the home and were supported by staff to access the community to make small purchases. At the time of the visit the home was busy and the residents were excited about going on holiday the following week. Fourteen requirements have been issued in respect of this visit to the home, two requirements have been repeated from a previous inspection and one immediate requirement was issued. A further failure to meet the requirements repeated for the second time will result in further action being taken. What the service does well: The home has done well to produce an accessible Service User Guide that describes the home the facilities provides and the support the residents can expect from the staff, however the home must ensure those residents wishing a have a copy receive one. The home does well to support prospective residents to test drive the home prior to making a decision if they wish to move in. Good records are kept on the outcome of the visits made by the prospective resident. The home in part demonstrates that it respects the wishes of the residents and produces in some cases clear and precise care plans, however further work is required in this area. The home does well to support residents to access the local community to purchase personal requisites, attend appointments and participate in local groups such as church and peer group activities. One resident informed the inspector that he had been supported by staff to pay his rent and then had purchased personal items of his choice in the local shopping precinct. The service does well to provide each resident with a room of their own that is pleasantly decorated and furnished to reflect the residents’ hobbies and interests. One resident stated he really liked his room, and another proudly DS0000011806.V249989.R01.S.doc Version 5.0 Page 6 showed his room to the inspector stating he was really happy with it. The home is pleasantly decorated and furnished with quality furnishings. Some of the residents stated that they had assisted to choose the decoration of the home and their bedrooms. What has improved since the last inspection? What they could do better: There is evidence of some good work going on in the home in terms of supporting the residents as detailed above in “What the home does well” however unfortunately in many cases identified through the body of the report what the home does well is countered out by what the home needs to do better. For example the home has a very good assessment document, however the one viewed by the inspector had not been completed properly. The home has developed in some case very good specific care plans that provide detail on how residents need to be supported with their personal care and daily activity, however this was not the case for all plans and there were areas identified in the residents’ personal health and welfare that had not been appropriately addressed and recorded. Through observation there was evidence that the residents are supported to make choices and evidence of person centred planning taking place, however the home needs to improve the approach it has undertaken to ensure the wishes, dreams and desires the residents express are appropriately met through the person centred process. The home does not fully protect residents from risk of harm, environmental risks to the residents such as exposed radiators in bathrooms have not been addressed, some staff have started in the home without the appropriate checks such as CRB and POVA checks being undertaken and the home has not met the requirement to seek advice from the Fire Authority on appropriate fire door closures. The manager is advised that a further failure to meet the requirement to address the issue of residents bedroom doors being inappropriately held open will result in further action being taken. An immediate requirement was issued at the time of the visit in respect of starting staff before undertaking appropriate employment checks. The home must ensure staff are appropriately trained in person centred planning and report writing. Remarks seen in one plan and the recorded DS0000011806.V249989.R01.S.doc Version 5.0 Page 7 approach to meeting a potential challenge had been recorded in a derogatory manner in respect of the resident. In addition the manager must ensure she makes herself aware of all current legislation to ensure correct procedures are adopted and followed in the home. 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. DS0000011806.V249989.R01.S.doc Version 5.0 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 DS0000011806.V249989.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 4 The existing residents have been made aware of facilities and services provided by the home, however the home is advised to ensure new residents to the home are informed. The home undertakes an assessment process prior to admission and supports residents to test-drive the home before moving in, however information provided by others such as social workers and existing carers must be included in the assessment and go on to form the plan of care. EVIDENCE: The home has developed an accessible Service User Guide for the residents who currently live in the home. Following the previous visit to the home the manager was advised to provide the residents with a copy of their own. There was evidence to suggest that a meeting had taken place with the residents to establish if they would like a copy. Some residents were recorded as declining and others requested a copy. The home currently has a vacancy, however the home is currently supporting a prospective resident to visit the home on a regular basis to test drive the home and see if they would like to move in. The home has kept good records of the outcomes of the visit and this is forming a basis for the final assessment. The home has undertaken an assessment of the perspective resident and obtained an assessment from the local placing authority, however the homes DS0000011806.V249989.R01.S.doc Version 5.0 Page 10 assessment document had not been fully completed and further information provided by the service users current care staff had not been included in the assessment. Therefore the home must ensure if following the trial period they can support the perspective resident then they must ensure the information provided by others is incorporated in the resident’s personal plan. DS0000011806.V249989.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 The home attempts to provide a continuity of care through the care planning process and in part demonstrates that it respects the wishes, needs and desires of the residents, however further work is required to make real the residents’ personal wishes and to minimise risks to the residents. EVIDENCE: The inspector viewed four residents’ personal plans and with the assistance of three of the residents viewed their person centred plans. The home ensures each resident has a personal plan that provides personal information on the residents NOK, GP, social worker, dentist etc. and how their specific personal, health and welfare needs must be met. The residents’ personal plans are regularly reviewed by the resident’s keyworker and there was evidence of some residents being involved in reviewing their plans. This demonstrates that the home respects the residents’ wishes to be involved in their care. One resident with whom the inspector met with stated he regularly looked at his personal plan with his keyworker. However comments made in one of the plans made by a member of staff had been written in a derogatory way. The manager is advised to ensure staff receive training in report writing DS0000011806.V249989.R01.S.doc Version 5.0 Page 12 and the value of writing information about residents in a respectful way. The manager must also ensure when there is a specific area of concern relating to an individual’s health and welfare that could impinge on the residents’ rights, and wellbeing that this is addressed through specific plans with assistance from other professionals. Staff then must be provided with support and advice on how to address the concerns. The home undertakes risk assessments on residents where there is an area of risk to their health and welfare, however at the time of the visit there was no evidence to suggest that the manager had undertaken a risk assessment and developed a risk management plan as required for one resident identified during a previous visit to the home. The inspector was shown a number of risk assessments pertaining to the resident, however these did not describe how the risks to others could be minimised, therefore the inspector took the view that the previously made requirement had not been met. (However since the visit to the home the manager has provided the inspector with a copy of the plan that indicates it had been done prior to this visit). The manager must ensure her deputy is aware of where all information and documentation pertaining to the residents, staff and the home are kept. The home is currently experiencing difficulties with the same resident and there is evidence that one resident has been harmed and other residents and staff are being placed at potential risk. The manager must also ensure areas identified as risk to the residents such as exposed radiators in bedrooms and bathrooms are undertaken and the appropriate action taken to minimise the risk. The home demonstrates that it supports the residents to make choices and decisions about their day-to-day lives. This was observed at the time of the visit where staff were observed to provide informed choices, offer advice and make arrangements to support the residents in their day-to-day activity. The residents talked excitedly about a forthcoming holiday, which they stated they had chosen themselves. However the development of person centred planning and the opportunity for residents to truly express their dreams, wishes and desires cannot be evidenced as being real for the resident. Three residents shared their person centred plans with the inspector, however evidence suggested that the residents were not fully aware of their person centred plans and they didn’t appear to ring true for them. The residents do not have ownership of their plans and there is no evidence to suggest the residents had stated they wanted them kept in the bottom of a filing cabinet under other files in the office. One resident didn’t appear to be aware of their person centred plan and another could not relate to the information in his plan as his life had changed significantly since the plan was first developed, the residents daily activity had changed and he no longer receives support from advocacy services. The person centred plan focused on the residents day to day activity, their likes and dislikes and dreams such as going on holiday, and living at St Winifred’s but did not include the important people in their life, life history or a life map. It was questioned how real the plans were to the residents. The home DS0000011806.V249989.R01.S.doc Version 5.0 Page 13 is required to review their approach to person centred planning and seek advice from the appropriate professional to assist in the understanding and development of the plans with the residents. Training is required for staff. The inspector recognises to introduce person centred planning and to support the process correctly takes time, as it must be driven by the resident and not the service. Therefore there will be no set timescale on the completion however the process will be continually reviewed during further visits to the home and requirements will be made if there is no evidence to suggest person centred planning is taking place. DS0000011806.V249989.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13 The home supports residents to have a presence within their local community and take part in peer and cultural activities. However the home must address the residents’ activity through a person centred approach to ensure residents are undertaking activities of their choice. EVIDENCE: The inspector observed through the course of the day, through speaking with the residents and reading residents personal plans that the residents are supported and encouraged to participate in everyday activities and life skills. Such as assisting with the shopping, collecting benefits, attending clubs and lunches and church. The person centred plans that the inspector viewed with the residents identified a number of activities the residents like or enjoy participating in. However as stated in standard six some of the information regarding activity was out of date and the resident could not relate to the activity. One of the plans identified a specific sport and the team he supports, however when asked if he had attended the sporting event he replied that he hadn’t. DS0000011806.V249989.R01.S.doc Version 5.0 Page 15 Therefore as identified in standard six the home needs to undertake a person centred approach to seeking the wishes and dreams of the residents to ensure that they are undertaking activites that are rewarding and fulfilling and not just those that are essential to everyday life. DS0000011806.V249989.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19 The home supports residents with their personal care in the way they prefer and ensures in part that residents’ health care needs are appropriately met, however further work is required to ensure all the areas of the residents health care needs are appropriately met. EVIDENCE: The inspector established from viewing residents’ care plans and speaking with staff that the residents are supported with their personal care in a way that is appropriate for them. Care plans provide detail on how the residents must be supported with specific areas of their personal care, and there was evidence that the plans are regularly reviewed. This provides support to the staff to enable them to provide a consistency of care. The home has a keyworker system where individual staff have responsibility for supporting or co supporting a resident assisting them with their personal care needs and ensuring their needs are being appropriately met. Some of the residents were aware of their keyworker and appeared to look forward to them coming into work. The inspector established through personal plans and discussion with staff that all residents are supported to attend health care appointments and receive support from appropriate health care specialist when required. However through discussion the inspector established that further work is required to DS0000011806.V249989.R01.S.doc Version 5.0 Page 17 ensure a medical problem exacerbated by the resident’s mental health difficulties is appropriately addressed therefore the home must make a referral to the appropriate specialist. The home must also ensure that specific care plans are developed to support the resident with areas of their health needs such as the use of insulin, and monitoring food and drink intake. Where a health care concern impacts on the resident’s life, i.e. not able to visit relatives as they have done so for many years then the home must seek alternative ways in which the resident can continue to do what is important to them. The manager is advised to seek advice from the appropriate professionals on how this can be done. DS0000011806.V249989.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Standard 22 was not fully assessed on this occasion. The home attempts to protect residents from abuse, however further work is required to ensure the home follows the correct polices and procedures. EVIDENCE: A resident with whom the inspector met with stated if he were unhappy he would tell the manager or a member of staff. There is an accessible complaints procedure incorporated into the Service User Guide, however not all residents have access to the Service User Guide. The manager must ensure those residents who wish to have a copy of the guide and the complaints procedure are issued with one. The member of staff with whom the inspector met with was able to demonstrate their understanding of what constituted abuse and what they would do if a resident stated that they had been abused. The home demonstrated recently that they took seriously the allegation made by a resident against another living in the home. This is subsequently being investigated through an adult protection forum, however the manager must ensure she makes herself and her staff aware of the policies and procedures when reporting allegations of abuse i.e. such as the role of the Commission for Social Care Inspection in the protection of vulnerable adults. The area of concern identified in standard 9 demonstrates that the manager had not taken reasonable precautions to protect other residents from being harmed. The manager must also ensure she fully protects residents by following the correct legislation on the recruitment of staff. Staff must not begin working in a home with vulnerable adults if they have not had the appropriate checks such as the Protection of Vulnerable Adults (POVA) and Criminal Bureau Checks. DS0000011806.V249989.R01.S.doc Version 5.0 Page 19 DS0000011806.V249989.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 27 The home provides a comfortable environment for the resident to live, however the home must ensure it makes safe all areas considered a risk to the residents. EVIDENCE: The home is a large pre-war building situated on the outskirts of Southampton City Centre. It has been tastefully decorated and furnished throughout. A separate lounge dining and kitchen provides amble space and an opportunity for the resident to choose where they want to spend their time whilst at home. Each resident has a room of their own decorated and furnished to their liking. There is an ongoing routine of redecoration and furnishing, one of the residents informed the inspector that his room was going to be decorated whilst he was away on holiday and another was to have a new carpet laid. The residents’ bedrooms reflect their individual character and interests and are homely and comfortable. The manager must ensure a headboard is fitted to the newly purchased bed before the new resident moves in. The home has ample toilet and bathroom facilities, in addition the residents have hand washbasins in their bedrooms. However the following areas of concern identified at the time of the visit in relation to the bathrooms and the rest of the home must be addressed. DS0000011806.V249989.R01.S.doc Version 5.0 Page 21 (1) (2) (3) (4) (5) The manager must ensure the bathroom identified at the time of the visit with the exposed radiator is covered without delay. In the meantime all residents using the bathroom must be risked against burning themselves. The manager must ensure all exposed radiators including those in residents bedrooms are risked assessed without delay and covered where the risk is identified as medium – high. The toilet seat identified as damaged and worn at the time of the visit must be replaced. The chipped tile in the bathroom identified at the time of the visit must be repaired or replaced, to prevent residents from cutting themselves on it. The door to the vacant bedroom must be fixed in order that it opens without sticking. The kitchen is looking old and well worn, the home would benefit from a complete refurbishment of kitchen cupboards and doors. The manager is advised to consider making application to the housing provider for the renewal or replacement of all kitchen cupboards and doors. DS0000011806.V249989.R01.S.doc Version 5.0 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 The home ensures staff receive adequate training to meet the needs of the residents, however further training is required to ensure residents are appropriately supported. EVIDENCE: The home has an appropriate training programme to equip staff with the basic skills of supporting the residents and people with learning disabilities. The home provides mandatory training such as fire training and first aid and resident specific training such as the Learning Disability Award Framework and medication training, staff are also encouraged to undertake a National Vocational Award in care. The inspector spoke with one member of staff who stated she felt she had been supported and equipped to undertake her roles and responsibilities in supporting the residents. However throughout the course of the visit the inspector established that some of the identified needs of the residents had not been fully addressed and training was required for staff. The member of staff with whom the inspector spoke with had some understanding of her role to support the residents in a respectful way, provide them with opportunities to develop new skills and access the community, however the member of staff was not fully aware of person centred planning and there was evidence to suggest in care plans that not all staff are aware on how to appropriately write reports or appropriately record outcomes for the residents. Therefore the manager must arrange for staff to receive training in person centred planning and report writing. DS0000011806.V249989.R01.S.doc Version 5.0 Page 23 The inspector viewed two new staff members’ records with the deputy manager. The inspector established by viewing the records that not all appropriate checks had been undertaken on newly appointed staff who were working in the home, (as stated in standard 23). Following various phone calls by the deputy manager to senior managers and administrators, it was concluded that they were not fully aware of the procedures in terms of employing new staff since July 2004, therefore it could not be confirmed what checks had been undertaken on the new staff. An immediate requirement was issued at the time of the visit for the manager to obtain the appropriate records and make herself aware of the legislation implemented on 26th July 2004. The home puts residents at risk by not following the correct recruitment procedures. DS0000011806.V249989.R01.S.doc Version 5.0 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 Standard 37 could not be fully assessed on this occasion, as the registered manager was not available at the time of the inspection. The home attempts to safeguard the residents’ health, safety and welfare, however further work is required to ensure areas identified as a risk through the report and standard 42 are addressed. (This standard was not fully assessed on this occasion). EVIDENCE: The manager was registered in April 2005 and has more than two years experience working with the people with learning disabilities. The outcome of the visit has identified a number of areas where the manager needs to make herself aware of current legislation to ensure the home is well managed and the residents are protected. This will be followed up during the next visit to the home. The manager must also ensure her deputy are fully aware of where information and documentation pertaining to the residents, staff and the home is kept. DS0000011806.V249989.R01.S.doc Version 5.0 Page 25 There was evidence to suggest the home undertakes the appropriate checks to guard against fire, however the manager must ensure residents do not wedge their bedroom doors open. The registered manager must seek advice from the Hampshire Fire and Rescue Service on the appropriate mechanisms to hold open fire doors. DS0000011806.V249989.R01.S.doc Version 5.0 Page 26 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 x 3 x Standard No 22 23 Score x 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 1 x x x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x x 1 2 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x DS0000011806.V249989.R01.S.doc Version 5.0 Page 27 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 YA2 Regulation 14 (1)a Requirement The registered manager must ensure that prospective residents’ assessed needs are fully and appropriately recorded. The registered manager must develop specific care plans to enable staff to provide specific approaches when maintaining the health and welfare of individual residents. The manager must seek advice from the appropriate professional when devising specific plans that could impinge on the residents’ rights and prevent residents carrying out activities of their choice. The registered manager must ensure the person centred approach adopted by the home to meet the needs, dreams, aspirations and wishes is made “real” by DS0000011806.V249989.R01.S.doc Timescale for action 31/10/05 2 YA6, YA18, YA23, 12(1)a, b 31/10/05 3 YA6, YA12, YA13, YA19, YA23 12(1)a, b 13(1)b 30/11/05 4 YA7, YA12 & YA13 12(2)(3) 12(4)a 31/03/06 Version 5.0 Page 28 measurable outcomes and continuous evaluation. 5 YA7, YA12, YA13, YA35 18(1)a, c(i) The registered manager must ensure the staff are trained in person centred planning to ensure the dreams, wishes and desires expressed by the residents are appropriately supported. The registered manager must ensure staff receive training in completing reports and residents plans in a respectful manner. The registered manager must ensure all residents are risked assessed against all areas of the home that could cause potential harm. Risk assessments must be undertaken in exposed radiators in residents’ bedrooms and bathrooms and action taken to minimise the risk. 8 YA23 13(6) 18(1)c(i) 10(3) The registered manager must ensure she makes herself and her staff aware of the policies and procedures when reporting allegations of abuse. The registered manager must ensure a headboard is fitted to the newly purchased bed before the new resident moves in. 30/10/05 30/11/05 6 YA7, YA17 & YA 35 18(1)a, c(i) 30/11/05 7 YA9, YA24 13(2)a, b, c 31/10/05 9 YA26 16(2)c 30/10/05 10 YA24 13 a, b, c 23(2)p The registered manager must 10/10/05 ensure the bathroom identified at the time of the visit with the exposed radiator is covered without delay. DS0000011806.V249989.R01.S.doc Version 5.0 Page 29 In the meantime all residents using the bathroom must be risked against burning themselves. 11 YA24 13 a, b, c 23(2) p The registered manager must ensure all exposed radiators including in residents’ bedrooms are risked assessed without delay and covered where the risk is identified as medium – high. The registered manager must ensure the damaged toilet seat identified at the time of the visit is replaced. 10/10/05 12 YA27 23(2) c 31/10/05 13 YA27 23(2) c 13(4)a, b, c The registered manager must ensure chipped tile in the 10/10/05 bathroom identified at the time of the visit must be repaired or replaced, to prevent residents from cutting themselves on it. The registered manager must ensure the door to the vacant resident bedroom is fixed in order that it opens without sticking. The registered manager after consultation with the fire authority must install appropriate devices to hold open residents bedroom doors. This requirement has been repeated. A further failure to comply will result in further action being taken. 31/10/05 14 YA24 &YA25 23(2) b 15 YA42 23(4) c(i) 31/10/05 DS0000011806.V249989.R01.S.doc Version 5.0 Page 30 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 YA24 Good Practice Recommendations The registered manager is advised to consult with the housing provider regarding the refurbishment of the kitchen. The registered manager is advised to ensure her deputy is made fully aware of where information required for inspection is kept. 2 YA9, YA37 DS0000011806.V249989.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 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 DS0000011806.V249989.R01.S.doc Version 5.0 Page 32 - 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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