Inspection on 08/12/06 for 9 Victoria Street

This inspection was carried out on 8th December 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

9 Victoria Street 26/09/07

9 Victoria Street 01/02/06

9 Victoria Street 09/11/04

9 Victoria Street 30/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Victoria Street (9) New Brimington Chesterfield Derbyshire S43 1HY Lead Inspector Denise Bate Key Unannounced Inspection 8th December 2006 09:30 Victoria Street (9) DS0000035806.V319174.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 Victoria Street (9) DS0000035806.V319174.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. Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Street (9) Address New Brimington Chesterfield Derbyshire S43 1HY 01246 347590 02146 347594 Not given www.derbyshire.gov.uk Derbyshire County Council 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) Linda Hurst Care Home 18 Category(ies) of Learning disability (16), Learning disability over registration, with number 65 years of age (2) of places Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: 9 Victoria St is a care home registered to provide personal care and accommodation for up to 18 adults between 18 - 65 and up to 2 adults over 65 with learning disabilities. The home is located in the village of Brimington on the outskirts of Chesterfield. A number of shops, pubs and other amenities are nearby. Derbyshire County Council owns the home. The accommodation is on two floors. There is a stair lift provided. 16 of the bedrooms are single accommodation, 4 of which provide ensuite facilities. One-bedroom is double accommodation. There are three communal dining and lounge areas. There is also a flat where service users can make drinks and snacks. There is a spacious garden to the side and rear of the building. Some limited car parking space is provided, although cars can also park on the road. Current charges are up to £649.55. Service users have an individual financial assessment to assess their contribution towards charges. There are no extra charges as service users access services in the community for hairdressing, chiropody, etc. Service users are expected to pay for taxis out of their mobility allowance. The amenities fund usually pays for transport for outings, with meals etc. being paid from personal allowances. Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection which lasted 7 hours. Four service users and a relative were spoken with during the inspection to ascertain their views of the home. The manager and three staff member were interviewed. Written information was provided by the manager prior to the inspection. Five service user surveys were received prior to the inspection providing feedback on the service. The views of service users not present on the day of inspection may not be adequately represented in this report. An assessment was made of the progress by the registered persons to address the requirements made at previous inspections. Further information and clarification were provided after the inspection on a number of issues. A number of records were examined, including care planning documentation, minutes of meetings, regulation 26 visit records, staff files and medication records. Three service users were case tracked. A tour of the building took place. The inspector took lunch with the service users and staff which provided an opportunity to talk informally. The service user guide and statement of purpose were provided and read after the inspection. What the service does well: What has improved since the last inspection? Service users are now able to get drinks at any time. Policies and procedures have been updated. The bathroom has been redecorated. Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose contained some information that was not up to date so did not reflect the service actually being provided. Not all service users have a full assessment before they come into the home, this may have implications for the staffing levels at the home and for other service users. EVIDENCE: A copy of the statement of purpose was given to the inspector and read the day after inspection. At the last inspection the need for more detailed information being given was brought to the attention of the home. The statement of purpose says that the home only takes long term care service users, and that home does not provide short term care/respite assessment or intermediate treatment. Information given on the day of inspection was that home sometimes takes residents in emergencies usually when elderly carers have fallen ill, or direct from the police station. They may not be known to the service so it may not be possible to do a full assessment. Staff training achievements were not up to date in the statement of purpose. Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 9 This home has a changing group of service users. It has been identified as a permanent placement for only one service user, although many service users have been there for some years. Discussions with the manager indicated that alternative arrangements were being actively sought for several service users. Some service users spoken to liked living at Victoria Street, one service user felt there were too many rules and wanted to move on. The pre inspection questionnaire indicated that 12 admissions and 12 discharges had taken place over a 12 month period. Copies of assessments and care plans carried out by social workers or care managers were seen on some casetracked files. One service user spoken to commented that they did not have enough information about the home before they moved in. The service user guide is presented in appropriate format for people with learning difficulties. One service users says she keeps her copy in her bedroom drawer. Copies of contracts were seen on case tracked service users files. The inspector was informed that all service users had been sent a letter about the recent changes in contract. Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans and risk assessments relating to personal and social care needs of residents are sometimes not completed in sufficient detail to direct and inform staff on how individual needs should be met which could put service users at risk. EVIDENCE: Three service users were case tracked. At the last inspection a number of comments were made about the systems operated by the home. From the care planning documentation seen on the day of inspection it would appear these issues are still outstanding. Some service users spoken with said that they discussed their care with their key-worker. Service users also referred to the regular service users’ meetings, Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 11 which take place independently of staff, with an external advocate. Unfortunately staff involvement was not reflected in some of the personal service plans and monthly reports checked. Personal service plans were not signed by service users, although two care plans drawn up by social workers had been signed by service users some time in the past. Personal service plans seen identified needs but were not detailed or specific about how needs were to be met. The homes monthly reviews were not filled in consistently for service users casetracked. A weekly timetable had not been updated. Risk assessments had been done, but were not detailed as to how risks were to be reduced. Some specific problems were discussed with the manager. There was evidence of reviews taking place which were often multidiciplinary and sometimes very detailed and involving the service user. Care planning documention had some evidence of choices being recorded. Current and old care planning documentation is kept together in the same file. It was not always clear whether some plans, e.g. behaviour modification regimes, were current or old. Sometimes there may be a conflict between individual needs (e.g. to eat healthy diet) and service user choice. It should be clearly recorded how these matters are going to be resolved to give clear instructions to staff. It is acknowledged that some service users may have difficulty understanding the documentation but further work is still needed to involve people in this process. The incident book was looked at. Several instances were recorded where there has been conflict between service users. Staffing levels can restrict choice, e.g. if staff need to accompany service users on outings, or in the evening service users have to go to their rooms at 10 oclock because there is only one night staff on duty. It is recognised that the home may not be able to meet all the preferences of service users of different ages, abilities and needs, and where this is so this should be clearly documented. There is a service user meeting each month with an independent advocate. Records of the meetings are produced in an appropriate format. The manager meets with the advocate after the meeting. The statement of purpose outlines the home’s policy to encourage independence. Most service users look after their own rooms and do their own washing. The flat is available for service users to learn to cook. Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides limited outings, activities and individual and group support which may effect the quality of life of service users. EVIDENCE: The statement of purpose outlines a commitment to helping service users develop lifeskills. Service users are aged between 20 and 74, so range of choices of educational, social, culture and recreation are needed to meet their individual preferences and range of abilities. Most service users have contacts with the local community and attend a variety of day centres and take part in activities. The home are hoping to develop more in house activites. The range of ages and abilities makes planning in house difficult sometimes. This may become more of an issue as people may not be able to afford to go out as they did much previously. Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 13 Plans for Christmas are in place. A member of staff and service users were going out to buy the tree on day of inspection and a pantomime was due to be held on Friday. At lunch and throughout the day of inspection staff were observed consulting and discussing day to day choices with service users. It was observed that most service users had positive relationships with staff. The service users spoken to said they got on well with their key worker. Within the staff meeting minutes it was recorded that individual service users are discussed and a change of key worker considered if appropriate. The inspector took lunch with service users and staff. It was of good quality and service users spoken to said they liked the food. Service users can now have drinks at any time. There is a kitchen in the ‘flat’ which can be used to develop independence skills, e.g. cooking and meal preparation. Some service users said they do have ‘one to one’ time with their key workers As previously mentioned, staffing levels do limit some service user choices. Staff spoken to indicate they do their best to do good job within the limitations of the staffing levels and varying needs of the service users. There have been recent changes in funding which have effected the amount of money residents have to spend. Several staff expressed concern about the impact on service users of having less spending money. Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Healthcare records were documented and the home is pro-active in seeking help with health concerns ensuring that service users health needs were met. EVIDENCE: As previously stated, most service users are planning to move on to other homes or into the community so Victoria Street is not seen as long term permanent home. There is a wide age and ability range so not all service users are interested in the same style of life. Within this context staff do work hard to meet individual social and emotional needs, but staff restrictions and the nature of communal living set limits on choices. However, the principles of respect and dignity are set out in the statement of purpose and most service users spoken to felt they were treated with dignity and respect. Care planning doucmentation includes medical details and doctors visits, appointments etc. On case tracked service users documentation there were Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 15 copies of letters and assessments from other health professionals, e.g. psychologists. Several indivdual service users were discussed with the manager during the course of the inspection. The inspector was informed that there are no service users who look after their own medication. If this situation arose the home would undertake a risk assesment. Medication records were seen for casetracked service users and were satisfactory. Signatures of staff who administer medication was seen. No eye drops were in use on day of inspection; the home’s practice is to write on the date of opening. Medication is stored in the office, which was very warm on the day of inspection. The home did not have a copy of the Derbyshire County Council Guidance on the administration of medication in care homes. A copy of the Royal Pharmaceutical Society guidance was available. The manager said the home’s procedures are regularly audited by the dispensing chemist. Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 16 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. There were a number of omissions in the recording of complaints indicating that service users may not be confident that any issues raised would be acted on effectively and promptly. Safeguarding adults procedures are in place to ensure service users safety is maintained. EVIDENCE: The home has a complaints and compliments book. There were several recent letters and cards expressing thanks for the service provided, but no recent complaints recorded. The inspector was informed that service users are not given a separate copy of the complaints procedure, although they do have a copy of the service user guide. The service user guide outlines the complaints procedure, which is to contact the manager or management team, or the quality assurance manager at Derbyshire County Council. No timescales are included. The service user guide does contain details of how to contact the Commission for Social Care Inspection. Three formal complaints had been sent to the service manager and copies also sent to the Commission. Information was given to the inspectior on the day of inspection regarding these complaints. However, there was no written record of the complaints nor of how the complaints were resolved, although the written records may well be collated centrally. No regulation 37 had been sent Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 17 to the Commission in relation thefts. No regulation 37 had been sent to the Commission in relation to another matter relating to the welbeing of a service user. Although this matter was dealt with under the Derbyshire County Council Complaints procedure by the service manager, a record should have been kept at the home clearly identifying the complaint and the action taken to resolve it. Confidential information should be kept separately from the ‘complaints and compliments book’. As previously mentioned, there is a wide range of age and level of need amongst the service user group at this home. Some service users have challenging behaviour, or patters of behaviour that can impact on the quality of life for other service users. It was noted that when there was friction between service users these were recorded as incidents. One issue raised by a service user was recorded on incident sheet. Service users at the home have access to an independent advocate whom they meet with on a monthly basis. Minutes are written up of the meetings, and feedback given to the manager either by the advocate or a service user. Some matters raised are issues that service users are not satisfied with. Consideration should be given to entering them into the complaints book to ensure that a clear audit trail is kept. Two staff files had copies of Criminal Records Bureau checks, and one had a copy of an application form and reference. The inspector was informed that staff information on Criminal Records Bureau checks is held centrally not at the home. Application forms and references are also kept centrally, but the inspector was informed that these are seen by managers carrying out interviews. The safeguarding adults arrangements were discussed with the manager and the home follow the Derbyshire County Council Procedures. One matter was discussed with the manager. The inspector was informed that all staff have had training in safeguarding adults, apart from a new member of staff. Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 18 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, 25, 27, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides service users with a comfortable place to live. EVIDENCE: The building is large and accommodation is arranged on two stories. Generally the building is maintained satisfactorily. One toilet was blocked and was being repaired on day of inspection. There is a choice of dining/lounge areas and all residents have their own room. There were pictures of the garden displayed, everyone worked hard in the summer to make garden a pleasant area to enjoy. The new mosaic outside the front door is very attractive. Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 19 Some bedrooms and the flat have been decorated since the last inspection. The kitchen may be decorated in the near future. Victoria Street (9) DS0000035806.V319174.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A trained and competent workforce are in place which attempt to meet the dependency needs and choices of service users currently accommodated within the home. EVIDENCE: The inspector was informed that there are usually two carers and a manager on duty. There is only one waking night staff on after 10 o’clock. This limits service user choice as service users have to go to their room at 10 o’clock. Staff are available for some outings and to support individuals. However, they are not always able to do so. Staff confirm that they have regular supervision and feel supported by managers. Staff felt there was good teamwork at the home and that they always tried to help each other. Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 21 Individual training certificates were seen on file. The manager said mandatory training was up to date, although one member of staff has to do adult protection training. At present 50 of staff are trained to NVQ level 3. Staff spoken to felt they were offered training opportunities. Three staff files were seen. They did not have required information on file at the home, although the inspector was informed that Criminal Record Bureau checks, references and application forms are held centrally. There were photos of staff on a display board at the entrance the the home. Victoria Street (9) DS0000035806.V319174.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, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users do not always have their views taken into account and the lack of formal quality assurance monitoring means evidence that service users benefit from a well run home is not provided. EVIDENCE: The registered manager is suitably experienced and also manages the domicilliary care service which is based at the home. There are two deputy managers. One deputy is the only member of staff with the registered manager award. Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 23 The home is visited regularly by a representative of the registered person and Regulation 26 visit reports were made available to the inspector. These indicated that some matters of day to day management are discussed and monitored. A quality assurance exercise had not yet been formally completed so no Your views Our Actions plan has been made available to service users. One small office is used as a medication room, managers office, handover office, and is the only office space available to other care staff members. Staff sometimes have to write up logs and care plans in the communal area. The creation of a large office would mean more space for administrative tasks. Residents’ monies are kept in the safe and manual records kept. The inspector was informed that this system is working satisfactorily. A representative of the county council is appointee for two people. Some service users manage their own finances. A new policy and procedures manual that is service specific has been introduced. The pre inspection questionnaire informed the inspector that all equipment had been serviced and matters relating to health and safety were in order. The manager informed the inspector that matters relating to health and safety are managed by one of the deputy managers. Fire safety training takes place every six months. No records were checked on this occasion. Victoria Street (9) DS0000035806.V319174.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 2 2 2 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 x 34 2 35 2 36 x 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 2 13 2 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 2 x 2 x x 3 x Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 4 Requirement Timescale for action 30/04/07 2 YA6 15 3. YA6 15 (2) (b) 4. YA33 18 (1) The statement of purpose must be updated to reflect that emergency care is sometimes provided and how the home will assess and meet that service users’ needs. Information on staff training should be up to date. Personal Service plans must 30/04/07 include details on how assessed needs are to be met, and risk assessments must include details on how identified risks are to be managed. Service user plans must be 30/04/07 reviewed with the service user and other relevant parties as agreed with the service user at least every 6 months or as changes occur, and updated to reflect changing needs. (Original timescales 30th June 2005 and 30/4/06) Staffing levels must be reviewed 30/04/07 taking into account dependency levels and the assessed needs of service users. The numbers of staff on duty must allow for uninterrupted work with individuals; activities; DS0000035806.V319174.R01.S.doc Version 5.2 Victoria Street (9) Page 26 5 6 YA22 YA23 22 (1) (5) 37 (1) (e) (f) 13 (6) 7 YA23 8 YA39 24 community links and social inclusion and administration duties. (Original timescale 30th June 2005 and 30/04/06) The home must keep a record of all complaints. Regulation 37 reports must be sent on all matters that might adversely affect the well being or safety of any service user. Evidence that CRB checks, references and employment history are satisfactory must be made available within the home. The home must carry out an independent quality assurance exercise involving service users, and information arising from this survey should be made available to service users and their advocates and used as the basis for developing an action plan. A copy must be sent to the Commission. 28/02/07 28/02/07 28/03/07 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA8 Good Practice Recommendations The registered manager should consider ways that service users can further participate in the day-to-day running of the home and to contribute to the development and review of the service. (Recommendation from previous inspection) There should be an assessment of individuals’ independent living skills and provision for development of these skills to be made. (Recommendation from previous inspection) The registered person should ensure that service users have access to and can choose from a range of appropriate DS0000035806.V319174.R01.S.doc Version 5.2 Page 27 2 3 YA11 YA14 Victoria Street (9) 4 5 6 7 8 YA20 YA24 YA22 YA22 YA37 9 10 YA37 YA39 leisure activities. (Recommendation from previous inspection) The temperature in the office should be monitored to ensure that medication is stored at a safe temperature. The home should be organised into clusters of up to 10 people by 1 April 2007. (Recommendation from previous inspections) Some issues raised with the advocate at the monthly service user meeting should be entered into the complaints book. Timescales should be included in the complaints information given to service users. The home should give consideration to extending the office so that managers and other staff are able to carry out their administrative and other duties (e.g. handover meetings, medication administration) in privacy and without overcrowding. The manager should undertake the registered managers qualification The registered manager should be able to demonstrate development for each service user, linked to implementation of the individual plan. (Recommendation from previous inspection) Victoria Street (9) DS0000035806.V319174.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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