Inspection on 14/03/07 for 81 Lowther Street

This inspection was carried out on 14th March 2007.

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

Other inspections for this house

81 Lowther Street 17/08/07

81 Lowther Street 23/11/05

81 Lowther Street 27/06/05

81 Lowther Street 21/02/05

81 Lowther Street 28/06/04

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

CARE HOME ADULTS 18-65 81 Lowther Street Whitehaven Cumbria CA28 7RB Lead Inspector Liz Kelley Unannounced Inspection 5 & 14 March 2007 09:30 th th 81 Lowther Street DS0000029268.V324421.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 81 Lowther Street DS0000029268.V324421.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. 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 81 Lowther Street Address Whitehaven Cumbria CA28 7RB 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) 01946 691234 The Croftlands Trust Mr Mark Barrett Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 6 service users to include: up to 6 service users in the category of MD (Mental disorder under 65 years of age) up to 3 service users in the category of MD(E) (Mental disorder over 65 years of age) 23rd November 2005 Date of last inspection Brief Description of the Service: The home is operated by The Croftlands Trust; a non-profit making organisation, which runs a number of residential and community based services in the County for people with mental heath problems. Six places are available to respond to people with severe and enduring mental health illness, living in the community who are in need of short-term crisis intervention and to reduce the need for a hospital admission. The average length of stay is around three weeks and the home takes over 100 admissions every year. 81 Lowther Street is a large Georgian property situated in the town centre of Whitehaven. It is therefore, central for all amenities, transport links and is convenient for both service users and visitors. Each person is given a bedroom of their own and use of a communal lounge, dining room, no smoking lounge and kitchens. Service users are not charged for the service as the Health Authority fund the scheme. The admission criteria states that individuals must be under the care of a mental health team in either the Allerdale or Copeland area. The home is managed by Mark Barrett, two staff are on duty and an aftercare 24 hours telephone support line is also available. 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection where all the key standards were examined and included two visits to the home. On the first visit, 05/03/07, time was spent with service users to seek their experiences of using the service. On the second visit 14/03/07 the deputy was available to assist in the inspection; and staff, resident’s records and administration files were examined. Feedback cards had been received from residents, relatives and professionals. A tour of the building was carried out, and the home returned a questionnaire which included the latest details of the service. What the service does well: What has improved since the last inspection? What they could do better: Some of the following issues have been identified by the management of the service for improvement and the other areas they are keen to work on to ensure that service users gain maximum benefit from their stay. 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 6 Overall care planning is inconsistent and plans lack detail or individual goals. Identification of mental health needs could be strengthened along with clearer details of a person’s mental health status. Use of daily/monthly reports and care planning should be reviewed with a view to making them relevant to meeting mental health assessed need, and in being proactive and engaging of service users. There should be a clear succession from identification of needs through to instructions to staff and desired outcomes agreed with service users. The management structure of the home needs to be reviewed to ensure that it can meet the requirements of running such a complex service. This should include a full Quality Assurance system that monitors the quality and consistency of the service. Both the Manager and Deputy require dedicated time to carry out their managerial tasks to allow for the effective running of the home. Complaints and safeguarding adults procedures need to be strengthened. Both require training and better supervision of staff to ensure that these areas are identified and processed in a way that protects service users and ensures that they are listened to. Supervisions and appraisals are not being carried out as frequently as they should be to give staff support and guidance in their role. These supervisions should clearly identify support needs and issues regarding the quality of care delivered. Training for staff to dispense and care for medications has been internal and this needs to be more formal to ensure that staff are competent in this area. This was stated at 27.5.05 inspection and has not taken place. This must be actioned as a priority as staff are handling complex medications that are crucial to ensuring a successful placement. The home’s systems of recording and dispensing medication should be reviewed to reduce recurring errors. In particular medication must be counter checked, and any errors must be reported to Commission for Social Care Inspection(CSCI). Other important events must also be reported to CSCI such as staff disciplinary issues and allegations of abuse. A Training matrix is recommended for the home which would help in identifying shortfalls, along with individual training files with copies of certificates would also be good practice. This would help to develop staff training in a way that meets the needs of the individual and provides service users with a balanced and well-qualified staff team. 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 7 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. 81 Lowther Street DS0000029268.V324421.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 81 Lowther Street DS0000029268.V324421.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 81 Lowther Street continues to be a unique service in the area and, therefore real choice is limited. However all residents stated they would chose this service over a hospital setting and good quality information is available prior to moving in. EVIDENCE: A positive development is the recent change in emphasis in referrals to crisis and responsive services and a move away from planned regular stays. The home has reviewed its effectiveness in the continuum of care for people with mental health problems in light of other community developments. To this end it has expanded its geographical intake for referrals to include North Cumbria. And in line with meeting equal opportunity legislation the project now takes service users over the age of 65 where there is a clear mental health need. The admission criterion is well-developed and ensures appropriate placements. Another recent development has been the introduction of a more in depth assessment carried out by the home in the first few days of a persons placement. This has been a positive move as it allows people to make a connection with their keyworker early on in their stay, and to examine the key 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 10 issues of their mental health that led to their admission. Staff described the use of further tools to assist in this process, namely a “spider diagram” which visually charts a person’s progress in key areas that affect their mental health, graphically displaying this information at admission and then plotting progress throughout their stay in the home. There was evidence that these were being completed to good standards and involved face-to-face sessions with service users to ensure they were clear on the reasons for their admission and the outcome hoped for. 81 Lowther Street DS0000029268.V324421.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 adequate. This judgement has been made using available evidence including a visit to this service. While service users are being offered individualised support that reduces the need for hospitalisation, and speeds up a return to their own homes, the administration systems to support this process need to be strengthened. EVIDENCE: The approach of the home is in line with the Care Programme Approach recommended for mental health service users. Service users are mostly knowledgeable of their care plans and goals which leads to a good compliance and success rate. The project is currently working to improve its care planning system. The majority of those examined were set up within a couple of days of arrival. However some had significant delays and one person’s had not to be filled in for the full length of their stay, which amounted to several weeks. The content of the care plans could also be further strengthened as the detail in some care plans was not sufficient to inform staff, and a number of care 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 12 plans were identical. Care plans need to be made more specific to the individual and the expected outcome clear, including the role that staff have to play. There should be a clear audit trail of needs from the newly developed assessments to the care plan. This in turn may affect how daily reports are written, as they in turn do not have a clear function. An end of placement report also ensures successful continuity to living in the community and up-dating other professionals. Recently a number of these have not been completed within the expected time-scale and commented upon in regulation 26 visits. The management systems in the home need to include a quality check for completing care plans, end of placement reports and other important reports to ensure these are carried out to acceptable standards and are within required dead-lines. A full review is needed of the care planning system used by the home and the supportive tools and reports to ensure these provide continuity and can assist in promoting improvements in people’s mental health. 81 Lowther Street DS0000029268.V324421.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. Personal development and making informed decisions is a key feature for individuals while at Lowther Street and the staff team are skilled at supporting service users to make these choices. EVIDENCE: The service is successful at providing a safe and therapeutic environment where residents can explore the nature of their current illness and personal circumstances. To assist in this, service users are encouraged to have a range of interests and are encouraged to maintain and develop appropriate relationships within the community. Care plans indicated that they are in contact with relevant professionals, such as community psychiatric nurses, to assist in developing their life skills and coping strategies. 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 14 The home has developed a good balance between risk-taking and a duty of care, and much of the dialogue with service users is around rights, choices and developing positive coping strategies. Service users are treated as individuals and their rights and needs respected and addressed. A good quality and healthy diet is identified as a key feature in promoting a persons well-being whilst staying a the Home. Menus are planned with service users on a weekly basis and a communal evening meal is encouraged. Service users spoke of very much enjoying the food and appreciated having a cooked meal in the evenings and are encouraged to make snacks and light meals across the day and to carry out shopping for the house. Staff are given training on the importance of healthy diets and the role in promoting good mental health. 81 Lowther Street DS0000029268.V324421.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 adequate. This judgement has been made using available evidence including a visit to this service. The health needs of service users are monitored and appropriate action taken. However, the area of medications could be handled more efficiently and proactively to ensure the home is appropriately and safely meeting individual service user’s needs. EVIDENCE: Records seen by the inspector confirmed that service users had a full range of access to general health care services and more specialised services, such as psychiatrists, community psychiatric nurses (CPN) and behaviour specialists. Service users spoken to felt staff were approachable and were helping them to achieve greater stability and promote their mental well-being, and felt this support was offered at the right levels, without being too intrusive. The home has a medication policy which is accessible to staff, medications are generally up-to-date for each service user and medicines received, administered and disposed of are recorded. The home makes up their own medication sheets as service users come from various points- home, hospital and use many different pharmacists. Service users are encouraged to take prescriptions to pharmacist as part of their recovery programme. 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 16 The Deputy stated that when a service user arrives one of the first tasks is for staff to check in medications and fill in a medication sheet. When questioned this was not counter checked by another member of staff. This is recommended to reduce errors. Training for staff to dispense and care for medications has been internal and this needs to be more formal to ensure that staff are up-to-date. This was stated at 27.5.05 inspection and has not taken place. This must be actioned as a priority as staff are handling complex medications that are crucial to ensuring a successful placement. Service users are not given the opportunity to self-medicate and this responsibility is handed over on return to their own homes. Service users come down to the office and are watched as they take their medication, this is reminiscent of a hospital or institutional setting. This limits opportunities for monitoring compliance as part of their recovery programme. The home should consider if this may be appropriate for some people as part of a recovery strategy. 81 Lowther Street DS0000029268.V324421.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 and 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Complaints and safeguarding of adults issues are currently not handled well by the home. Consequently some service users have had a negative experience of living at the home and this has impacted on their mental health. EVIDENCE: The home has a complaints procedure that meets the National Minimum Standard. However, there was evidence that a number of complaints made by service users and professionals have not been investigated according to this policy. This has led to some service users feeling that they are not listen to and there have been reports that service users have chosen not to use the service due to complaints not being resolved satisfactorily. Staff also feel that these complaints and issues have not been taken seriously enough, and have gone on too long. This has affected the atmosphere of the home and the morale of staff is low. There was evidence in the home to suggest that their had been four complaints from service users and two from professionals but only one of these was recorded and followed according to the guidance. One of the main ways for service users to complain is by using a complaints book held in the hall. This method is not confidential and not conducive to service users making a complaint. The home needs to ensure that their policy is followed and that a more user-friendly, non-threatening way for service users is devised that has clear methods of feedback, and quality checking. 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 18 As the reporting and recording of complaints has been poor this has had a negative knock on effect to an ongoing staff disciplinary matter. Staff also demonstrated a lack of sufficient knowledge regarding safeguarding of adults procedures. There was evidence of possible allegations that were not referred to social services, and that were also not satisfactorily handled by the home. The home should not be investigating allegations of abuse, these must be referred to social services for consideration. Staff in the home have not had any training outside of their induction training on abuse. Senior staff in the home must attended training devised to assist them in leading teams on this issue. The organisation as a whole has a need for senior staff to attend this course, as the same mistakes are reoccurring across the organisation. 81 Lowther Street DS0000029268.V324421.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a homely, comfortable, clean house which they feel is far preferable to the institutional feel of a hospital setting. EVIDENCE: The lounge had been redecorated with new curtains and cushions and service users said it was much more homely. Service users said they appreciated having a key to their bedrooms and having a non-smoking lounge. They also thought the location of the home was very convenient for local facilities and the town centre, and had enjoyed going out for walks around the town centre and harbour. Service users have joint responsibility with staff to keep the house and their rooms clean and tidy and this is handled well by staff who support service users to carry out these tasks. The deputy is responsible for the maintenance and upkeep of the property and this is managed well ensuring the house is safe and comfortable. Two bedrooms had just been refurbished as part of this programme. 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. Development and supervision of staff is inconsistent and leads to a patchy service offered to service users. EVIDENCE: The service recognises the importance of training, and tries to deliver a programme that meets any statutory requirements and the National Minimum Standards. The organisation has a training team to deliver and organise training for its workers. The manager is aware that there are some gaps in the training programme and plans to deal with these. The service also recognises when additional training is needed and uses connections with the mental health team to access short courses. The Home has only two members of care staff qualified to a minimum of NVQ level 2 in Care. This was required to be a minimum of 50 by 2005. Care staff have completed other short training courses to help them in their role, eg Health and Safety at work, and a number of short courses on Management of violence and break way techniques. All senior team members would benefit from training in staff supervision. Four staff have completed the 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 21 Community Mental Health Diploma and the home should determine if this is equivalent to an NVQ for the purposes of meeting this NMS. A Training matrix is recommended for the home which would help in identifying shortfalls, along with individual training files with copies of certificates would also be good practice. This would help to develop staff training in a way that meets the needs of the individual and provides service users with a balanced and well-qualified staff team. Two members of staff are qualified mental health nurses and the organisation should assist these staff in keeping their registration current by offering guidance, support and training. The service has a recruitment procedure that meets the regulations and the National Minimum Standards. While the majority of recruitment practices are satisfactory the manager needs to ensure that the home has up-to-date duplicate copies for staff recruitment files from the HR department and that individual training records are kept. All staff have enhanced level CRB disclosure checks. Upon appointment staff are issued with a handbook, which includes job descriptions and terms and conditions. Appointments are subject to a six-month probationary period. The Croftlands Trust has a code of conduct and all members of staff have a statement of terms and conditions. The home could further improve its recruitment procedure by including service users as part of the selection procedure for new staff. Supervisions and Appraisals are not being carried out as frequently as they should be to give staff support and guidance in their role. These supervisions should clearly identify support needs and issues regarding the quality of care delivered. The home should develop core competencies which staff are expected to adhere to, and these should be key to staff supervisions and development. The service needs to ensure that senior staff have both the training and the dedicated hours to carry out this role. 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 22 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 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The running and management structure of the home is in need of strengthening to ensure that it is effective in ensuring the well-being of service users. EVIDENCE: Feedback from service users and professionals is that this is a unique service that plays a vital role in the continuum of care and support to people with mental health problems. It has plays an important role in supporting people outside of a hospital setting. However, due to the nature of the service it has a very high turnover of service users. This creates a significant amount of additional work and co-ordination is paramount. The current manager also manages other projects for the Croftland Trust and this limits hours spent in the home to approximately 50 per week. The deputy, therefore, has a significant role to play but has only a few hours each month to carry out this supervisory role. The amount of paperwork, 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 23 frequent contact with professionals, and supporting service users, many of whom have far more complex and challenging needs than before, has put this management structure under strain. Consequently the management role and systems have been detrimentally effected. This is illustrated in other sections of the report, for example care planning needs an overhaul, staff development and supervision require better coordination, and elements of poor practice should have been tackled much sooner and to better effect. Complaints require more careful management along with any resulting disciplinary functions. Quality Assurance is not currently happening, including monitoring of staff to ensure they are doing tasks such as completing care plans and end of placement reports, carrying out fire records and fire instructions to staff. The home does not currently seek service users views on the service they receive. Each person is given a Commission for Social Care Inspection feedback card after each stay, but the home does not use their own methods of seeking feedback. Staff and managers are working to capacity, and although are hard working and dedicated, this results in the home lacking effective co-ordination. The management and staff roles within the service would benefit from a review to determine how best to take the service forward and improve on the issues mentioned. 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 24 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 1 23 1 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 2 x 1 x x 2 x 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 25 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement Timescale for action 30/06/07 2 YA9 13(4) 3 YA20 18 (1c) Care plans must be individualised, set out positive planned interventions and any restrictions on choice and freedom (agreed with the service user) imposed by a specialist programme. They must be set up within a reasonable timescale and regularly up-date with the service user. Individual risk assessments 30/06/07 must demonstrate how service users are consulted and detail risk management strategies should be recorded in the individual plan, and reviewed. Staff must receive 30/06/07 accredited training in the care of medicines The homes complaints procedure must be reviewed to ensure it is user-friendly, and that staff listen to, identify and act upon the views and concerns of service users DS0000029268.V324421.R01.S.doc 4 YA22 22 30/06/07 81 Lowther Street Version 5.2 Page 26 5 YA23 6 YA36 7 YA39 and others. The recording of complaints must also improve. 13 Robust procedures for 30/04/07 responding to suspicion or evidence of abuse or neglect (including whistleblowing) must be followed to ensure the safety and protection of service users. The home must not investigate these allegations in isolation. 18(2) Staff must be appropriately 30/04/07 supervised and supported with regular formal supervision sessions which are used to constructively develop staff skills in working with service users 24(1)(a)(b)(2)(3) Effective quality assurance 30/06/07 and quality monitoring systems, based on seeking the views of service users, must be in place to measure success in achieving the aims, objectives and statement of purpose of the home. 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. 2. 3. Refer to Standard YA7 YA20 YA23 Good Practice Recommendations How staff promote decision-making, and any restrictions imposed via the assessment process, should be clearly demonstrated in the service users plan. A more robust checking in system for medication is recommended to reduce chances of error Staff should be familiar with the local multi-disciplinary guidance on Adult Protection DS0000029268.V324421.R01.S.doc Version 5.2 Page 27 81 Lowther Street 4 5 6 7 YA32 YA34 YA35 YA37 The home should develop core competencies, that staff are expected to adhere to, and these should be key to staff supervisions and development. The home should be using service users as part of their recruitment process for new staff A training and development plan is recommended to effectively plan and co-ordinate both the future of the project and staff training needs The management and staff roles within the service would benefit from a review to determine how best to take the service forward and improve the service offered to service users. 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 81 Lowther Street DS0000029268.V324421.R01.S.doc Version 5.2 Page 29 - 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!