Inspection on 04/05/07 for Amersall Court

This inspection was carried out on 4th May 2007.

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

Other inspections for this house

Amersall Court 10/05/06

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 4 th May 2007 10:45 DS0000065521.V331755.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 DS0000065521.V331755.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. DS0000065521.V331755.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Amersall Court Address Amersall Road Scawthorpe Doncaster South Yorkshire DN5 9PQ 01302 781857 01302 788624 NONE 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 DS0000065521.V331755.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specific service user under the age of 65, named on variation dated 18th September 2006, may reside at the home 10th May 2006 Date of last inspection 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 accommodation is provided in four bungalows, Three bungalows provide single bedrooms with en-suite toilets and showers, a communal lounge and kitchen/dining room. A two-bedded unit for semiindependent living 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 £899:27 per week, as at May2007. Additional charges are made for hairdressing, Chiropody, toiletries, magazines/papers, taxis and contribution to petrol and holidays, these cost are variable for further information contact the home. Information about the service is available to service users and their families via the home’s Statement of Purpose and the Service User Guide. The home last published inspection report is kept in the office, which is available on request for visitors to read. DS0000065521.V331755.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this Key Unannounced Inspection, which took place from the 4th May 2007 over two days for 10:30 hours. The home is registered for 18 beds; at the time of inspection 14 service users were residing in the home. Prior to the inspection the manager submitted a pre-inspection questionnaire giving information regarding the home and services provided. Analysis of this information and other relevant documentation for example, notifications and complaints were carried out before the inspection. Prior the inspection comment cards were sent out to the home for them to distribute. Five were sent to service users all were received back but two service users declined to complete these surveys. Five were sent to staff members two were received back. Five were sent to professionals who had contact with the home three were received back. All these comments are included in this report. During the inspection documentation and records were examined for example, medication, complaints, accident records, staff rotas, staff training files and case tracking of three service users care plans, these were cross-referenced with other relevant documentation relating to those service users. Information was gathered from as many different individuals as possible, for example, discussion with service users (personal preferences to be called this) and individual interviews with members of staff, including the manager. A tour of the premises and direct observation of staff interaction with service users was carried out throughout the inspection. The inspector would like to thank all the staff and service users for their cooperation in the inspection process, and any issues or concerns that were raised were discussed with the manager at the end of the Inspection. What the service does well: During the visit lots of verbal and non-verbal communication between staff and service users, it was a very welcoming and friendly atmosphere within the home. A number of positive comments were received from service user that could express themselves, “they were happy at the home both with care they received and staff”. “Feel that staff work hard at making them feel wanted and cared for”. Service users had been fully assessed prior to admission and lots of information was available to assist staff in caring for them. DS0000065521.V331755.R01.S.doc Version 5.2 Page 6 Most service users participated in a number of social and leisure activities based on personal preferences. 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. What has improved since the last inspection? What they could do better: Safe working practices, a number of issues were raised that may effect the health, safety and welfare of service users. The home must ensure safe storage of all hazardous substances, provide a safe system for the storage of clinical waste and all night staff must receive fire training and drills. These issues need to be given some priority to ensure welfare and safety of service users and staff at all times. Care plans and medication details must be monitored, reviewed, updated and fully accurate and contain sufficient information that reflects the care being delivered. Notification must be sent to the Commission without delay. The registered provider must ensure that they continue to fill the vacant posts at the home. Staffing levels must be sufficient to meet the increased needs of service users, ensure that staffing is assessed according to the dependency levels of service users. Evidence must be available to show that Regulation 26 visits to the home have taken place. The home must have more consultation with service users and relatives for their views of the home and the care that service users receive. Provision should be made for the storage of equipment. Corridor carpet throughout all the units within the home are showing signs of wear and tear and are in need of replacing. Provide further storages space, as the home had only one very small store cupboard. DS0000065521.V331755.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. DS0000065521.V331755.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 DS0000065521.V331755.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. People who use the service experience Good Quality outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. People that use the service were individually assessed prior to admission to ensure their needs would be met. EVIDENCE: Three care plans were case tracked of people that use the service. Care plans showed the history of service users, they had been individually assessed prior to admission to the home. Lots of information was available in individual care plans, these reflected any specialist interventions or other professionals that were involved. Risk assessments had been completed based on individual needs, including health action plans for all service users on unit 1. Staff said that the home ensured that any potential service users were encouraged to visit the home and spend time there before admission on a permanent basis. DS0000065521.V331755.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. People who use the service experience Adequate Quality outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. Care plans provided staff with sufficient information that ensured they could meet the care needs of service users, however care plans must be monitored and reviewed on a regular basis. EVIDENCE: Three service users care plans were case tracked and discussed with the manager, care staff, and service users. Care plans contained a range of information, relevant medical details, including evidence of other professional involved, medication details and all service users had signed a consent form for staff to administer their medication. Records showed when service users were seen by GP, district nurse or attended hospital. Feedback from health professional who said the service informs the district nursing service promptly if any concerns are raised or any advise is required. DS0000065521.V331755.R01.S.doc Version 5.2 Page 11 Various assessments had been completed for example nutrition, personal and oral hygiene. Health action plans were in place for those service users who had learning difficulties. Care plans showed that service users were supported in making decisions whenever possible. Risk assessments were in place and service users were supported to take risks as an independent lifestyle, limits were only imposed where risks were identified, e.g. going out alone. One service user said if the home stopped them taking that risk it would have a big impact on their life. Records showed that plans were in place to monitor behaviour when service users were aggressive and strategies were in place. However these records showed they are not always reviewed on a regular basis, and not sufficient information that showed how the home were handling medical concerns. A number of incidents had occurred and staff had been subjected to physical and verbal abuse from service users, not all these incidents had been reported on a regulation 37 forms to the Commission for Social Care Inspection. DS0000065521.V331755.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): 12,13,14,15,16,17. People who use the service experience Good Quality outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. The home provided and promoted communal living and leisure activities. People that use the service were given opportunities to mix with other people and spend time outside of the home. EVIDENCE: From observation on the day and speaking to people that use the service, their daily routines appeared flexible with some service users staying in bed if they wished, which was respected by staff. Interactions between staff and service users were positive with people being called by their preferred name, all being attended to promptly and staff respecting privacy by knocking on doors before entering. The home do not employ an activities organiser therefore its left to the staff to try and organise activities, this is dependent on staffing numbers. However from speaking to staff and service users all said they try to organise activities whenever possible and most people can choose to be involved in some form of day centre DS0000065521.V331755.R01.S.doc Version 5.2 Page 13 resource. Service users said they were encouraged to pursue their own interests or hobbies; one person goes to football matches on a regular basis. Religion was documented in care plans and people were supported if they wished to practice their religious beliefs. Service users said they are supported and encouraged to maintain links with their families and friends, majority people had contact with relatives and go on home leave. The home had its own mini bus to facilitate outings. Staff said that all people that use the service were offered the option of a holiday; service users said they are going on holiday in June with members of staff. Positive comments were received about the home and staff from service users seen on the day and on surveys received. For example, “staff work hard to improve their quality of life at the home” “staff make them feel wanted and cared for” “staff are available when I need them”. Mealtimes and menus were discussed, service users and staff organised menus on a weekly basis, and alternatives were always offered. Take-away meals were provided and meals out on occasions, at peoples preference. People that use the service were nutritional assessed, encouraged to eat healthy and weighed on a regular basis. DS0000065521.V331755.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. People who use the service experience Adequate Quality outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. Service users health is monitored and staff could access all NHS health care facilities. Staff must ensure that Medication policies and practices are followed to ensure safe recording and administration of all medicines. EVIDENCE: Care plans showed that service users had access to a range of health care professionals, including district nurses, chiropodists, dentists and optician. Staff supported service users to access these services; any contact with health care professionals was recorded. Some service users were able to comment on this those spoken to, who confirmed that they visit the dentist or opticians when required. Service users on the learning disability unit have a health action plan. Records clearly showed detailed information of service users personal care needs. Staff interviewed were aware of any restrictions on privacy, e.g. danger DS0000065521.V331755.R01.S.doc Version 5.2 Page 15 when bathing alone, and said risk assessments were in place to identify these risks. Each unit kept individual service users medication, appropriate storage facilities were provided. Medication stocks were checked and found expired medication in one cupboard, one tablet missing from nomad system. Medication records were examined on each unit with a number of issues being raised, medicine omitted no reason given. Hand written medication records were not signed by two staff members to ensure accurate recording. Medication stopped by GP was hand written by member of staff with no evidence why this was done. DS0000065521.V331755.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): People who use the service experience Good Quality outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. Service users and relatives are provided with information to enable them to raise concerns or complaints about the home and their care; staff had knowledge and understanding of adult protection issues, which promoted protection of service users from abuse. EVIDENCE: There were no recorded complaints since the last inspection. Surveys said that service users knew how to make a complaint. Discussion with staff and service users on the day said that they feel happy to raise any concerns with members of staff or management. The organisation had a comprehensive Concerns Complaints procedure (DMBC View Point). There is also a monitoring form that is used to record complaints, included timescales for complaints to be acknowledged and investigated. The home had DMBC policy on Adult Protection and Whistle blowing, and therefore the home had appropriate policies and procedures in place for dealing with adult protection and whistle blowing. Those staff spoken to were aware of these polices and procedures, and could state the action they would take on receiving any allegations. DS0000065521.V331755.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,30. People who use the service experience Adequate Quality outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. Service users live in a comfortable and accessible environment with any specialist equipment they require to maximise their independence. However the registered provider must take action regarding storages of hazardous substances and control of infection regarding clinical waste. EVIDENCE: The home was purpose built and designed to suit the service users group, corridors internally connect all of the accommodation. This is fully accessible for service users in units 2 3 and 4,but unit 1 has a keypad for service users safety, as Unit 1 accommodation is for service users with learning disabilities. All had adaptations and equipment to suit individual service user. Each unit has communal lounge and kitchen/dining room, unit 4 is a semiindependent unit which provides communal lounge/dining, kitchen and shared bathroom. DS0000065521.V331755.R01.S.doc Version 5.2 Page 18 Tour of all units found them to be comfortable bright and cheerful, all were made to look very homely with pictures and ornaments around the home. It was clean and tidy, with the exception of the corridor carpet throughout all the units showing signs of wear and tear. The grounds were well maintained, accessible communal patio to the rear of the home, garden furniture had been purchased for service users or visitors to use on nice days or when they had barbecues. Each of the three units provided single bedrooms with en-suite toilets and showers, most of the service users bedrooms had been individually decorated in a style to suit them. These 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 with furniture and fittings being of good quality. Each bungalow was also provided with a bathroom, which contained a specialist bath. Communal toilets were provided. The two-bed semi independent unit contained one shared bathroom. Tour of these facilities were being used as storerooms for wheelchairs, carpet cleaners and incontinent pads. The inspector was informed on the last inspection that outbuilding were going to be provided for further storages space, as the home had only one very small store cupboard. Further issues were raised re clinical waste bins, in bathrooms were very full. Once these bins were full, yellow bags were used for clinical waste, which remained in these bathrooms until collected which was once a week. The environmental health officer made a recent visit to the home, a number of requirements were made, and the manager said they were working towards resolving these issues. Issues were raised when visiting the laundry room, as hazardous substances were stored in an unlocked cupboard and the laundry room not locked. Staff were advised to keep the laundry door locked at all times until they resolve this issue. DS0000065521.V331755.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36. People who use the service experience Adequate Quality outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. The home had a very enthusiastic staff group that worked positively with people who use the service to improve their quality of life within the home. Staffing levels were maintained, only because staff work extra hours to cover vacant posts and sickness. This outcome is affected by a failure of the registered provider not filling the vacant posts for a long time and not providing evidence to support that staffing is assessed according to the dependency levels of service users. All these issues may affect the quality of care provided to people who use the service. EVIDENCE: Staff had the competencies and qualities required to meet service users needs, staffing numbers were discussed with the manager, staff on duty and duty rotas checked. These showed the manager continued to work on rota, when they were short staffed, therefore the service did not have sufficient supernumerary hours to undertake all of her managerial duties. DS0000065521.V331755.R01.S.doc Version 5.2 Page 20 Staff at the home covered duties over and above their contracted hours to ensure minimum numbers were maintained, which amounted to one hundred and sixteen hours every week for staff to cover. This is because one member of staff remains on long-term sick and one staff on maternity leave, plus the vacant posts at the home for care staff. From talking to staff, evidence in care plans and information in the preinspection questionnaire completed by the manager indicated that service users needs had increased over the years. No evidence was found that staffing is assessed according to the dependency levels of service users, for example at times staff had to leave there unit to help with a service user who needed two staff to assist with moving and handling. A review of staffing levels must take place, and provide evidence that the home staffing levels are sufficient to meet the increased needs of service users. Previous requirements made in relation to these issues have been carried forward. Each member of staff had an individual training file, these were examined and training opportunities were discussed with the manager and staff. Records indicated that 38 of the staff team had achieved National Vocational Qualification level 2 in care (NVQ) A number of staff had completed Learning Disability Award Framework (LADAF). Since the last Inspection access to mandatory training and refresher training for staff had improved. The home had a thorough recruitment procedure, staff recruitment records are held at the Councils head offices. However discussions with the manager, and new staff who were interviewed, confirmed they had been interviewed, Criminal Records Bureau checks completed, and two written references provided. Staff said they were given copies of the General Social care Council code of practice. Supervision of staff was discussed with the manager, staff on duty and records checked, which showed an improvement of staff receiving formal supervision, and yearly appraisal on a regular basis. DS0000065521.V331755.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42 People who use the service experience Adequate Quality outcomes in this area. This judgement has been made from evidence gathered during the inspection. This included a visit to this service and seeking the views and experiences of people who use the service. The outcome is affected by a failure of the registered provider not monitoring practice and compliance in record keeping. Detailed records would assist to ensure that people who use the service have their health, safety and welfare promoted and protected at all times. EVIDENCE: The manager has the relevant experience to run the home; she had worked at the home a long time and said she understands her responsibilities. The home did have some auditing systems in place, evidence was available that audits are completed e.g. residents finances, health and safety. No evidence was available to show that the home seeks the views of family, DS0000065521.V331755.R01.S.doc Version 5.2 Page 22 friends and stakeholders in the community. The Commission receives Regulation 26 visits and Regulation 37 incident forms but not on a regular basis. Records showed that some incidents involving aggressive outbursts from service users, had not always been recorded on regulation 37 incident forms. Health and safety was discussed with both the manager, staff and records checked. All staff spoken to were aware of policy and procedures, staff said they had access to all of the policies and procedures and confirmed they had completed fire training and drills. Fire systems within the home had been checked and serviced; weekly fire alarm checks were fully recorded and up to date. At the time of the visit no fire exits were blocked, however all hazardous substances was not securely stored. Staff training had improved since the last inspection, records showed that most staff had received updated training in moving and handling, health and safety food hygiene, first aid, and fire training and drills, with the exception of night staff completing fire drills. DS0000065521.V331755.R01.S.doc Version 5.2 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 2 25 3 26 3 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X 2 2 X DS0000065521.V331755.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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(2)(b) Requirement Timescale for action 10/06/07 2 YA20 13(2) 3 YA27 13(4)(a) Care plans must be monitored, reviewed and updated on a regular basis, and contains sufficient information that reflects the care being delivered. 07/05/07 Medication details including administration instructions must be transferred fully and accurately this refers to, 1) Two members of staff must sign hand written medication records sheets. 2) Medication stopped by GP. 3) Medication stocks must be checked to ensure they are in date. Bathrooms must not be used as 10/06/07 storerooms and must remain accessible to service users. Infection control the home must provide a safe system for the storage of clinical waste. The home must continue with on going NVQ training to ensure a minimum ratio of 50 of care staff are trained to NVQ Level 2 or equivalent must be achieved. 10/06/07 4 YA30 13(3) 5 YA32 18(1) (c)(i) 30/08/07 DS0000065521.V331755.R01.S.doc Version 5.2 Page 25 6 YA33 18(1)(a) 7 YA39 24 (3) 8 YA41 26(2)(b) 3&4 ( c) 9 10 YA41 YA42 17(2) Schedule4 13(4)(a) (c) 23(4)(d) The needs of service users must be reassessed; sufficient staff must then be employed to meet their needs. The manager must then be employed supernummary to the care staff. A summary of the outcome of this review and its outcome must be forwarded to the local C S C I office (Timescale of 30/06/06 not met) Effective quality assurance and quality monitoring systems must be implemented, based on seeking the views of service users. Systems must be put in place to measure success in achieving the aims, objectives and statement of purpose of the home. (Timescale of 31/08/06 not met). The responsible individual must ensure that they conduct Regulation 26 visits to the home and provide evidence of this. (Timescale of 01/06/06 not met). Notification must be sent to the Commission without delay. The home must ensure safe storage of all hazardous substances. All night staff must receive fire training and drills. 01/07/07 30/06/07 01/06/07 07/05/07 07/05/07 11 YA42 01/06/07 DS0000065521.V331755.R01.S.doc Version 5.2 Page 26 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 Refer to Standard YA24 YA23 Good Practice Recommendations Corridor carpet throughout all the units showing signs of wear and tear and in need of replacing. Provision should be made for the storage of equipment. DS0000065521.V331755.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000065521.V331755.R01.S.doc Version 5.2 Page 28 - 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!