Inspection on 10/05/06 for Amersall Court

This inspection was carried out on 10th May 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Amersall Court 04/05/07

Amersall Court 07/12/05

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

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

CARE HOME ADULTS 18-65 Amersall Court Amersall Road Scawthorpe Doncaster South Yorkshire DN5 9PQ Lead Inspector Janet McBride Key Unannounced Inspection 10th May 2006 10:45 Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 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 Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 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. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Amersall Court Address Amersall Road Scawthorpe Doncaster South Yorkshire DN5 9PQ 01302 781857 01302 788624 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) Doncaster MBC Ms Lynda Stocks Care Home 18 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4), Physical disability (14) of places Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: Amersall Court is a care home for adults offering care to two different service users groups aged 18 to 65 with physical disabilities/ learning disabilities, accommodating 18 service users. The Registered provider is Doncaster Metropolitan Borough Council (DMBC) The home was purpose built and has been opened for two years, and accommodation is in three bungalows, there is also a two-bedded unit for semi-independent living. Each of the three bungalows provides single bedrooms with en-suite toilets and showers, a communal lounge and kitchen/dining room. The semi-independent unit provides communal lounge/dining, kitchen and shared bathroom; corridors internally connect all of the accommodation. To the rear of the home is a large, enclosed patio area, and a car park is provided at the front of the home. Fees range from £863:86 per week, as at April 2006,and additional charges are made for hairdressing, Chiropody, toiletries, magazines/papers, taxis and contribution to petrol and holidays. The Statement of Purpose and the Service User Guide, which is available on request, this as information about the services available to residents and their families. The home last published inspection report is available on request and advised the home that a copy must be made available for visitors to read. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector from the Commission for Social Care Inspection carried out this unannounced inspection at Amersall Court started on the 10th of May 2006 and took place over two days (9:30 hours). The home is registered for 16 beds only 13 residents were in residing in the home at the time of Inspection. All 13 of these residents have complex needs and most require two staff to care for them, some could not communicate to the Inspector, therefore discussion with key workers and observation during the Inspection to gather information for this report. Pre-Inspection work was carried out for example, analysis of notifications and any other relevant documentation. During the Inspection various documentation and records were examined for example, medication records, staff rotas, staff training and also included case tracking of two-service users care plans, which were cross-referenced with other documentation. Prior to the visit eight questionnaires were sent to residents for their views on the service, and six were received back, also some were also spoken to on the day. This Inspection also included individual and group interviews with members of staff, and feedback from relatives and visitors on the day. Tour of the premises and direct and indirect observation of staff interaction with residents throughout the visit and information was gathered from as many different individuals as possible that had contact with the residents in their environment. The Inspector would like to thank all the staff and residents for their cooperation in the Inspection process, and any issues or concerns that were raised were discussed with the deputy manager during or at the end of the Inspection. What the service does well: The home provides a good standard of accommodation, with a good of furnishings throughout, also easy access to all parts of this single-storey building. Residents had been fully assessed prior to admission and lots of information was available to assist staff in caring for them. Most residents participated in a number of social and leisure activities based on personal preferences. Welcoming and friendly atmosphere within the home, and lots of verbal and non-verbal communication between staff and residents was noted throughout the time spent at the home. A number of comments received from those residents who could express themselves, “they were happy at the home both Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 6 with care they received and staff”. “Feel that staff work hard at making them feel wanted and cared for”. What has improved since the last inspection? What they could do better: The registered manager must ensure there is sufficient evidence to support the homes staffing levels, and that staffing is assessed according to the dependency levels of residents, all these issues may affect the quality of care provided to residents. Safe working practice, The Registered person must provide statutory training and updates for staff as highlighted in this report, this as been a requirement in a number of reports and needs to be given some priority to ensure welfare and safety of residents and staff. Recruitment, continue to fill the vacant posts at the home, and ensure that new staff are given copies of the General Social care Council code of practice. To continue to enrol staff on the NVQ level 2 training to ensure the 50 staff achievement target are reached as soon as possible. To have more consultation with residents and relatives, and if DMBC don’t have quality assurance questionnaire, one needs to be devised and sent to residents/representatives for their views of the home and the care that residents receive. Evidence must be available to show that Regulation 26 visits to the home have taken place. The registered providers and manager need to sustain the progress made since the last Inspection by continuing to review the services provided at the home. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 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. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 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 Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 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): 2 Quality in this outcome area for standard is good. This judgement has been made using the written evidence available in care plans and discussions with staff. Prospective service users are individually assessed prior to admission to the home, to ensure that their needs will be met. EVIDENCE: Three residents care plans were case tracked and evidence was seen that service users are individually assessed prior to admission to the home, to ensure that their needs will be met. Lots of information was available in individual care plans, evidence that other professionals are involved and that care plans are developed based on individual needs, including health action plans for all service users on unit 1. Those staff that were interviewed evidenced a commitment to service users, to ensure that all their needs will be met and were aware of any limitations there may be, these would be were recorded and agreed in the individual plan. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 679 Quality in this outcome area for those standard assessed is Good. This judgement has been made using available evidence including a visit to this service, including examination of documents discussion with staff and residents in the home. The care plans provide staff with sufficient information to ensure they can meet the needs of residents. EVIDENCE: Each service user had an individual plan of care; two individual care plans were case tracked, and one more was examined for further information regarding a Regulation 37 received. Those care plans seen contained a range of information; various assessment, relevant medical information including evidence of other professional involved, both care needs and personal information was also evident. For example health promotion, religious beliefs, health action plan for those residents who have Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 11 learning difficulties. The plans evidenced that they had been drawn up with the resident or their representative. Risk assessments were in place, and the plans identified the staff action required to ensure identified needs were met. Residents are supported to take risks as an independent lifestyle, any limitations were recorded and agreed in the individual plan, this was discussed with one resident and they said if the home stopped them taking that risk it would have a big impact on their life. Equality and diversity within the service was explored, both male and females Service users reside in the home, also there is a mix of male and female staff, it was evident that all residents were dressed appropriately according to their gender and their preferences. Records seen were up to date, legible, and relevant to the care residents are receiving. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 16 17 Quality in this outcome area for all standards assessed is Good. This judgement has been made using available evidence including a visit to this service and talking to residents and staff. Service users rights are respected and daily routines promote independence, individual choice and freedom of movement. Residents have access to a range of appropriate activities. EVIDENCE: From observation on the day and speaking to residents, their daily routines appear flexible with some residents staying in bed if they wished. Observations between staff and residents were good with residents being called by their preferred name, all being attended to promptly and staff respecting privacy by knocking on doors before entering. Most residents who choose to do so were involved in some form of education or day centre resource, and staff within the home try to organise activities whenever possible. Religion was documented in some care plans and residents were supported if they wished to practice their religious beliefs. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 13 Staff spoken to was aware of promoting equality of opportunities that suit residents gender when accessing leisure activities and tried to accommodate this where possible. The home do not employ an activities organiser therefore its left to the staff and at times this is dependent on staffing numbers. Evidence was seen that residents are supported and encouraged to maintain links with their families and friends. The home had an open visiting policy, the majority of residents had contact with relatives and go on home leave, and some residents are going on holiday in a few weeks with members of staff. Positive comments were received from residents about the home and staff for example, “felt that staff work hard to improve their quality of life at the home” “staff make them feel wanted and cared for” “have good relationships with staff members”. Mealtimes and menus were discussed, residents and staff organise the menus on a weekly basis, and alternatives are always offered. Take-away meals were provided and meals out on occasions, at the residents preference. Plentiful stocks of food were seen in the units and those residents that could comment said that they enjoyed the food. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 Quality in this outcome area for standards assessed is Good. This judgement has been made using available evidence in care plans and medication records, including a visit to this service. Medication policies and procedures are well managed and staff has the necessary skills to administer the medication to residents, ensuring their safety and protection. EVIDENCE: Care plans show that residents had access to a range of health care professionals, including District Nurses, Chiropodists, Dentists and Optician. Staff supported service users to access these, and any contact with health care professionals was recorded. Residents that were able to comment on this were spoken to, who confirmed that they visit the dentist or opticians when required. Residents on the learning disability unit have a health action plan. Records clearly show detailed information of residents personal care needs. Staff interviewed was aware of any restrictions on privacy, e.g. danger when bathing alone, and stated that risk assessments would be in place to identify these risks and how they can be managed, any issues relating to emotional health is dealt with on an individual basis, evidence was available to support this such as referrals to CPN services if required. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 15 Each bungalow kept individual residents medication, appropriate storage facilities were provided. Medication stocks and records were examined on each unit and all were found satisfactory. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Quality in this outcome area for standards assessed is Good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are provided with information to enable them to raise concerns or complaints about the home and the care provided, robust polices are in place to protect residents. EVIDENCE: The organisation has a comprehensive Concerns Complaints procedure (DMBC View Point). There is also a monitoring form that is used to record complaints, this meets the requirements and includes timescales for complaints to be acknowledged and investigated. No recorded complaints since the last Inspection, and discussed with staff and residents state that they feel happy to would raise any concerns with members of staff or management. The home has DMBC policy on Adult Protection and Whistle blowing, and therefore have the appropriate policies and procedures in place for dealing with adult protection. Discussion with staff confirmed they were aware of these polices and procedures. Since the last Inspection the Commission for Social Care Inspection has received notifications of any incidents that have happened within the home. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 26 28 30 Quality in this outcome area for standards assessed is good. This judgement has been made by visiting the premises and tour of the building and speaking to residents. Residents live in a safe, comfortable and accessible environment with any specialist equipment they require to maximise their independence. EVIDENCE: The home was purpose built and designed to suit the client group, corridors internally connect all of the accommodation, and is fully accessible for residents in units 2 3 and 4,but unit 1 has a keypad for residents safety, as Unit 1 accommodates four elderly residents with learning disabilities, but at the present only as three residents. Unit 2 and 3 both accommodate six residents with physical disabilities and unit 4 as two beds but at the present is being used for one-resident with physical disabilities, all have adaptations and equipment to suit the resident group. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 18 Each of the three bungalows provides single bedrooms with en-suite toilets and showers, most of the resident’s bedrooms had been individually decorated in a style for them, and rooms reflected the different interests and hobbies of each occupant. Each room had a lockable facility, a television, music centre, adjustable bed, overhead tracking, accessible electric points and suitable furniture, two of the residents were happy to show the Inspector their bedrooms. Each unit as communal lounge and kitchen/dining room, unit 4 semi-independent unit provides communal lounge/dining, kitchen and shared bathroom. Tour of all units was found to be comfortable, bright and cheerful and looked very homely with fresh flowers, pictures and ornaments around the home. It was well maintained, clean and tidy, with furniture and fittings being of good quality. The home had one domestic at the time of this inspection. Domestic arrangements have improved and this is reflected in the home, but no domestic cover at the weekends and care staff still undertakes some cleaning duties. The grounds were well maintained, but it was a sunny day and it was noted that the home don’t have any garden furniture for residents or visitors to sit on, when they have barbecues they have to take tables and chairs from inside the home. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 34 35 36 Quality in this outcome area for standard 32 33 34 and 35 is Adequate but improvement as been made in standard 36. This judgement has been made using available evidence in various documents and records including a visit to this service. The outcome is affected by a failure of the registered provider, not ensuring staff is appropriately trained and failure to achieve 50 of staff having NVQ level 2 by the required 2005 date, and not providing evidence to support that staffing is assessed according to the dependency levels of residents, all these issues may affect the quality of care provided to residents. EVIDENCE: Staff can access NVQ training the pre-inspection questionnaire completed by the manager indicated that 26 of the staff team had achieved NVQ level 2 in care. Therefore a previous requirement to achieve 50 of the staff team to be qualified has been carried forward. Staff had the competencies and qualities required to meet residents needs, and staffing was discussed with the deputy manager, staff on duty and examined of duty rotas. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 20 Although the home has recruited care staff since the last Inspection, the home still have some vacant posts for care staff, and are using agency staff when needed plus staff at the home covered duties over and above their contracted hours to ensure minimum numbers were maintained. From talking to staff and evidence in care plans and information in preinspection questionnaire completed by the manager indicated that residents needs had increased over the years, but no evidence was found that staffing is assessed according to the dependency levels of residents, therefore a review of staffing levels must take place, and provide evidence that the home staffing levels are sufficient to meet the increased needs of residents, this information should be made available to the Inspector. Previous requirements made in relation to these issues have been carried forward. The home had a thorough recruitment procedure, and staff recruitment records are held at the Councils head offices, however, the deputy and new staff that were interviewed were able to confirm that appropriate checks had taken place, all staff had undertaken Criminal Records Bureau checks, and provided two written references, but were not sure if staff are given copies of the General Social care Council code of practice. Training was discussed with the deputy manager, who stated that induction and foundation training remains the same for new staff. Two new members of staff were interviewed who confirmed they had received three days induction to the home, but one had not received moving and handling training and most residents require moving via a hoist, and this could have an impact of the safety of residents and staff. Each member of staff had an individual training profile, and although staff have the competencies and qualities required to meet residents needs, training files show that some staff has had updates in training, and a number of staff has started on the LADAF course, however quite a number of staff still require training or updates in moving and handling, food hygiene, health and safety and first aid training, this was also confirmed when interviewing staff. Previous requirements made in relation to these issues have been carried forward. Supervision of staff was discussed with the deputy manager, and staff in charge at the time of visit, also records checked, which show an improvement of staff receiving formal supervision, and a number of staff had received yearly appraisal. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 40 41 42 Quality in this outcome area for standards 39 41 and 42 is adequate, but improvement in standards 37 and 40. This judgement has been made using available evidence in various documents and records including a visit to this service. Staff at the home is enthusiastic and work positively with residents to improve their quality of life. The outcome is affected by a failure of the registered not providing statutory training and updates for staff, and staff are not receiving first aid training; and not reviewing the quality of care within the home, all these issues may affect the quality of care provided to residents. EVIDENCE: The registered manager has worked at the home a long time and understands her responsibilities, but on this Inspection she was on sick leave. However she did complete the pre-inspection questionnaire, and any issues from this were discussed with the deputy manager. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 22 Quality assurance was discussed with deputy manager and residents and any audits that were available were checked; no evidence was found that the home as a quality assurance system in place, therefore no evidence was found that views of residents and relatives were obtained. Feedback is usually sought at residents meetings at which minutes are taken, but no residents meetings have taken place since the last Inspection. Records required by Regulation 37 notifications have been received on a regular basis since the last inspection. Although the deputy manager and staff state that the care manager visits on a regular basis, only two Regulation 26 visit reports have been received therefore no written evidence was found that monthly visits take place. Health and safety was discussed with both the manager, staff and records checked. All staff spoken to was aware of policy and procedures, staff stated they have access to all of the policies and procedures and also confirmed they completed fire training and drills. The home had appropriate policies and procedures in place, however the majority of these require updating. At the time of the inspection no fire exits were blocked and all hazardous substances were securely stored. Evidence was seen that systems within the home were checked and serviced; also weekly fire alarm checks were fully recorded and up to date. Staff training records indicated that most staff required updated training in moving and handling, health and safety and food hygiene. This seems to be the consequence of training places not available, staff could not always be spared to attend training. It is imperative that staff undertakes all mandatory training at the required frequency to ensure safety and protection of residents and staff. Insufficient staff was trained in first aid to ensure a trained person was on duty at all times. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 3 2 2 X Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA32 Regulation 19 Requirement Timescale for action 2. YA33 18(1)(a) 3. YA34 18 4. YA35 18 The registered person must ensure that the home achieves a 31/08/06 50 NVQ staff attainment as soon as possible. Staffing, The Registered person must provide evidence that 30/06/06 staffing is sufficient to support Residents assessed needs at all times in accordance with the guidance recommended by the department of health. (Timescale of 31/1/06 not met) Recruitment, 1) Continue to fill the vacant posts at the home. 31/08/06 2) Ensure that staff is given copies of the General Social care Council code of practice. Training and development, The Registered provider must ensure that staff can access and receive training and updates, so 30/06/06 they are trained and competent to do their job.e.g. Moving and handling, health and safety, food hygiene and first aid. (Timescale of 28/3/06 not met) Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 25 5. YA39 24 6. YA41 17(1) Effective quality assurance and quality monitoring systems must be implemented, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. The Care manager must ensure that they conduct Regulation 26 visits to the home and provide evidence of this. Safe working practice, The Registered person must provide statutory training and updates for staff as highlighted in this report. 31/08/06 01/06/06 7 YA42 13 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA28 Good Practice Recommendations Provide garden furniture for residents or visitors to enjoy sitting in the garden. Amersall Court DS0000065521.V291339.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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. 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