CARE HOME ADULTS 18-65
Bethia Cottage Lelley Road Preston Hull East Yorkshire HU12 8TX Lead Inspector
Christina Bettison Unannounced Key Inspection 30th July 2007 09:30 DS0000062728.V346554.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 DS0000062728.V346554.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. DS0000062728.V346554.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Bethia Cottage Address Lelley Road Preston Hull East Yorkshire HU12 8TX 01482 891108 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) Milbury Care Services Limited Mrs Karina Whitehead Care Home 5 Category(ies) of Learning disability (5) registration, with number of places DS0000062728.V346554.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Registered for 5 service users in category LD, some or all of whom may have a physical disability 1st August 2006 Date of last inspection Brief Description of the Service: Bethia Cottage is a purpose built home situated on the outskirts of the small village of Preston some 6 miles from the city of Hull. There is no public transport service to or from the premises. The site offers two facilities Garfield Grange and Ashlyn a two-building respite service and Bethia Cottage for longer term placements. Bethia Cottage, opened in August 2005, gives permanent care to a maximum of five service users. The large detached building provides five single bedrooms, one with an en-suite facility. The service users in the other bedrooms share bathing and toilet facilities between two. There are sufficient communal areas and a large garden provided with outdoor seating. All service user facilities are on the ground floor. The small upper floor accommodation is used for staff purposes only. Specialist lifting, moving and safety equipment is provided as necessary. Bethia Cottage offers long term accommodation for adults with a learning disability and associated health and behavioural problems including some challenging behaviour. The staff seek to provide a holistic regime offering personal care, help, advice and guidance with daily living skills and activities, a catering service, a laundry service and domestic and cleaning services. Activities are offered both on and off site. The property is owned by Milbury Care Services who also provide the care input. DS0000062728.V346554.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was a key inspection and the unannounced site visit took place over one day on 30/07/07. All five service user surveys were returned, service users were assisted by staff and relatives to complete these, three relatives surveys were returned, twelve staff surveys were returned and one health and social care professional survey was returned. The registered manager, one senior support worker, and three support workers were spoken with on the day of inspection. Observations of care practices were undertaken to check if service users were receiving appropriate care to meet their needs. Service users that were at the home on the day of the visit were spoken with. The inspector looked around the home and looked at records. Information received by the CSCI since the previous inspection was also considered in forming a judgement. Prior to the visit the inspector referred to complaints received and notifications sent to the Commission for Social Care Inspection, the event history for the home over the past year and the completed pre-inspection questionnaire. The site visit was led by Regulation Inspector Mrs C Bettison and the visit lasted seven hours. Weekly fees range from £1,550 to £1,650 per person per week. Information on the service is made available to current service users via the statement of purpose, service user guide and inspection report What the service does well:
Service users have an assessment so that the staff know what they need to do to meet their needs and each service user has a range of plans that help the staff to know how their needs must be met. A Relative commented, “from………moving into Bethia Cottage, her needs have always been met.” All service users have a single room and either a shared bathroom or an en suite bathroom. All bedrooms are to service users own taste, providing them with an area where they can spend private time or receive visitors. Service users are helped to enjoy activities both in the home and in the community and holidays that meets their diverse needs. Relatives and parents are kept in contact with and service users are able to receive visits from their relatives.
DS0000062728.V346554.R01.S.doc Version 5.2 Page 6 The kitchens are kept clean and service users are helped to eat a healthy diet resulting in a healthier lifestyle. Service users and their relatives concerns are listened to and staff make sure they take action to sort problems out quickly. The staff and managers know that they need to make sure service users are protected from harm. When new staff are employed they are checked to make sure they are safe to work with the service users. The staff are very caring and competent and treat service users with respect and dignity. A relative commented, “the staff at Bethia Cottage are excellent,………always receives the best care and support from them.” The registered manager is qualified and competent to fulfil her role as the manager. The home is safe, comfortable and meets service users individual needs. When asked what do you feel the care home does well, a relative commented “…………is very well cared for (as are all of the other ladies who live at Bethia), a well balanced diet, personal hygiene and health, the whole building is exceptionally clean, care and support, safety issues, helping……..to live her life to the fullest potential, the manager and all staff are friendly. I feel they are all very lovely people who know how to care for disabled people.” What has improved since the last inspection?
Service users and their relatives have enough information that is easy to read so that they know what to expect from the home. A relative commented “staff are very good at giving information in all areas.” All service users now have a statement of terms and conditions that tells them how much they have to pay for the service and any other charges. The complaints procedure is now available in a way that helps service users to understand it and any complaints and the action taken to put things right are now written down. Staff are receiving all the training they need to be able to meet the needs of the service users living at the home. The manager has returned to the home and the home is being run well, staff said that they are assisted by a supportive manager. DS0000062728.V346554.R01.S.doc Version 5.2 Page 7 Two different vehicles are available to make sure that service users are able to use facilities outside of the home and records were available to show that service users enjoy a variety of activities in the community. A relative commented “the home struggled initially to provide the promised activities but it is improving, there are few indoor activities and the clientele are difficult to keep interested (short attention spans) so tend to wander about aimlessly.” A review of the service had been undertaken in the previous year and this years review has started by consulting with relatives and professionals to get their views on how the service meets the needs of the people who live there. What they could do better:
Two relatives in a survey commented that they did not feel that the staffing ratios were sufficient to meet the needs of all the ladies in the house and that staffing should be provided on 1:1 basis however this was not evidenced during the course of the inspection, staffing appeared to be adequate to meet the needs of service users. The manager should discuss these concerns with relatives and placing authorities to ascertain if funding arrangements and staff provided is adequate to meet the needs of service users. Staff need to keep a record of how service users needs are changing and how they are developing their independence skills and reviews of care need to be done at least every 6 months. When service users behave in a way that can be hard for staff to manage there must be a written plan to guide staff. A relative commented, “because another resident disrupts the home a lot …………does not get as much individual time as she would like. The resident was supposed to get 1:1 time but this does not happen.” Another commented “lots of time spent by staff looking after 1 client with behavioural problems. Detrimental to other clients - not sufficient staff.” Health action plans need to be produced and be detailed to cover all of service users health needs and the records need to say what happened at the appointment and what will happen next. When service user have medication that can be given “as and when required” there must be written guidelines for staff so that they know when they can give it. Staff who give out medication must be checked by the manager to make sure that they have the right skills. The bath in the en suite bedroom must repaired or replaced. The home needs to have maintenance and renewal plan and repairs and redecoration of the home needs to happen more quickly. DS0000062728.V346554.R01.S.doc Version 5.2 Page 8 All staff need to have an individual plan to say what their training needs are. 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. DS0000062728.V346554.R01.S.doc Version 5.2 Page 9 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 DS0000062728.V346554.R01.S.doc Version 5.2 Page 10 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 and 5 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed in full by a range of professionals and service users and their families are given sufficient information about the home so that they can be assured that the home can meet their needs. EVIDENCE: The home has a statement of purpose and this details all of the information required by this standard and Schedule 1 of the Care Homes Regulations 2001 for adults 18-65 years. A service user guide is available and this contains all the information required by National Minimum Standard 1.2 and is now provided in a format that to help service users understand it. Discussion with managers confirmed that all service users are funded up to £200 towards the cost of a 5 day holiday or a series of one day outings by the organisation as part of the contract price. It states in the homes own Service DS0000062728.V346554.R01.S.doc Version 5.2 Page 11 User guide “Milbury will pay the costs and staffing for one 5-day holiday per year or 5 day outings.” The care files of two service users were examined. These contained a copy of the Local Authority Community care assessment and care plan and a range of assessments carried out by a variety of professionals. The staff team had enough information on the assessed needs of the service user and this enabled them to provide an individually tailored service to meet the service users complex needs and ensure their emotional stability and healthy lifestyle. DS0000062728.V346554.R01.S.doc Version 5.2 Page 12 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 and 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the provision of service users plans, risk assessments and a consistent, knowledgeable and skilled staff team. EVIDENCE: Two care Files were examined in detail as part of the inspection process and another two care files were examined briefly to determine the quality of the service user plans. All service users have a care file, and the inspector was informed that the manager and staff have been transferring the service user plans and other supporting documentation into Milburys new corporate format. All but one service user plan had been transferred. Each file contained a personal profile, which gave staff a quick overview of a service users needs.
DS0000062728.V346554.R01.S.doc Version 5.2 Page 13 All but one of the service user plans examined contained a range of plans that were detailed and gave staff clear guidance on how to meet the needs of service users. These plans were supported by a range of risk assessments. However some plans did not include much detail of cultural and religious needs or finances and the recording of actions/plans and outcomes needs to be improved to ensure that the home can evidence the good work that they are doing and demonstrate how the service users needs are being met and how individuals are developing. A relative commented “more stimulation and input needed” better recording of inputs and outcomes would better evidence this. Service users at Bethia Cottage have complicated needs and one of them presents behaviours that may be a risk to themselves or others, the manager had consulted with Milburys behavioural therapy team for guidance in how to manage these behaviours. However the manager must develop detailed plans to tell staff how to manage this behaviour and protect people. Any techniques to be used must be discussed and agreed at a multi agency meeting and documented appropriately. A relative commented, “Because another resident disrupts the home a lot …………does not get as much individual time as she would like. The resident was supposed to get 1:1 time but this does not happen.” Another commented “lots of time spent by staff looking after one client with behavioural problems. Detrimental to other clients - not sufficient staff.” Feedback from professionals and observations evidenced that service users were happy with the service and that there needs were met and independence promoted in many ways. Both service user files contained copies of their care review coordinated by the care management team, however these were only convened annually. The inspector advised that a 6 monthly review must be held. A number of risks had been identified, assessed and were being minimised by the production of risk assessments that staff were familiar with and followed and a number of these related to measured risk taking allowing service users to develop and maintain their independence. All service users had a key worker. Staff and service users confidential information was observed to be securely kept and handled in accordance with the Data Protection Act. Lockable facilities were used and service users are consulted about when and where there information can be shared. Staff were observed to knock on doors and to ask permissions to enter bedrooms. DS0000062728.V346554.R01.S.doc Version 5.2 Page 14 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,and 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are assisted to continue their personal development and access a range of leisure pursuits of their choice. Family contact and personal relationships are maintained and all service users enjoy a healthy diet that ensures good outcomes in maintaining a healthy lifestyle. EVIDENCE: The service users that live at Bethia Cottage have significant care needs and all require a high level of support from the staff team. Therefore none of the service users have work placements. DS0000062728.V346554.R01.S.doc Version 5.2 Page 15 In care files examined and from discussion with the staff team it was evident that service users enjoy a variety of activities both within the home and out in the community. Examples of activities accessed included, swimming, bowling, walks, shopping, visiting the seaside, going out for bus rides and in the house there is a sensory environment and some service users like listening to music, some service users undertake some domestic chores and bedroom management with staff support. One of the service users enjoys a regular visit from a “pat” dog. There was evidence in the file and staff spoken to confirm that on the whole these activities take place regularly however staffing limitations do create problems on occasions, for example one of the service users requires two staff to support her to go swimming, the manager informed the inspector that different options were being explored to enable this to happen. The manager and staff promote a healthy eating menu. Breakfast is cereals, toast and fruit juice. The lunch menu consists of soup, toasted or ordinary sandwiches. The evening meal menu consisted of shepherds’ pie, curries, fish, pastas, chilli, lasagne, quiche and salads and on Sundays a full roast dinner. Restrictions regarding meals and/or lack of choice where clearly documented in the service user plans and guidelines and recommendations from the Dietician were being incorporated. DS0000062728.V346554.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users physical and emotional needs are met, by the provision of a wide range of healthcare professionals and outside agencies and a caring team of staff that promotes their privacy, dignity and respect. However this could be improved by better identification, planning and recording of outcomes to meeting health needs. EVIDENCE: Records examined confirmed that service users health needs were met by GP, dentist, chiropody, optician and that they had access to a wide range of other health professionals e.g. psychiatrist, psychologist, physiotherapist, epilepsy nurse and dietician. However there needs to be some improvement in the screening, identification and planning to meet health needs. Health action plans had not yet been produced. In addition to this the recording of outcomes to health appointments
DS0000062728.V346554.R01.S.doc Version 5.2 Page 17 did not identify outcomes therefore this could made it difficult to track if health needs had been met or not. Milbury Care has medication policies and procedures that include receipt, storage, administration and disposal of medication. Medication systems were on the whole well managed in the home, the home uses a monitored dosage system. There was no one self medicating and at the time of the visit and there were no controlled drugs in the home. All staff are given medication administration training, however, the manager has not assessed staff to ascertain their competence, this must be addressed. Some service users are prescribed medication for pain relief and for behaviour management purposes. Protocols for the administration of medication on an “as and when required” need to be produced so that staff know when to administer PRN medication and when additional doses can be given. DS0000062728.V346554.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are protected from harm by a robust complaints procedure and a Protection of Vulnerable Adults policy and procedure that the staff and manager are aware of their responsibilities within this. EVIDENCE: Milbury Care have a complaints procedure. This contained contact details for the CSCI and the ombudsman and gave an assurance that service users and their families would not be victimised for making a complaint. There had been one complaint since the previous inspection, which had been taken seriously, investigated and resolved appropriately. The manager checked the complaints log on a regular basis. DS0000062728.V346554.R01.S.doc Version 5.2 Page 19 The home had a copy of the “Multi agency Guidelines for the Protection of Vulnerable Adults” in respect of alerting, referral and investigation. There was evidence from the home’s recruitment and selection processes, staff training records, complaints log and the use of risk assessments that the manager ensured that on the whole service users were protected and safeguarded from abuse. Training records evidenced that staff had received training on the protection of vulnerable adults. DS0000062728.V346554.R01.S.doc Version 5.2 Page 20 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is safe, homely and comfortable and meets their assessed needs, however it would benefit from being better maintained and equipment being repaired or replaced more quickly. EVIDENCE: Bethia Cottage was registered and opened in August 2005. The large detached building provides five single bedrooms, one with an en-suite facility. The service users in the other bedrooms share bathing and toilet facilities between two. There are sufficient communal areas and a large garden provided with outdoor seating. All service user facilities are on the ground floor. The small upper
DS0000062728.V346554.R01.S.doc Version 5.2 Page 21 floor accommodation is used for staff purposes only. Specialist overhead tracking for lifting, moving and safety equipment is provided as necessary. At the time of inspection the house was showing some signs of wear and tear, with redecoration in specific areas required. In addition to this the bath in the en suite in bedroom 5 had been not working since October 2006 and if the service user wanted a bath she would have to use someone else’s bathroom or use the communal shower facility. This is unacceptable and the bath must be repaired immediately. The manager stated that there is a handyman that is shared between other houses. This does not appear to be effective in meeting the maintenance and redecoration requirements of the home and must be addressed. Outside of the building to one side is a very overgrown field, two of the service users bedrooms overlook this field and it is an eyesore and spoils the view for one of the ladies who likes to watch the birds feeding. The field is owned by Milbury Care, therefore, steps must be taken to ensure it is kept neat and tidy. DS0000062728.V346554.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported by a consistent, caring and skilled staff team ensuring good outcomes for service users. EVIDENCE: The inspector was informed that the home has 13 staff in total, comprising of • • • 1 x Registered manager 2 x senior support workers 10 x support workers The manager stated that that the staff team has been consistent since the home opened. However they currently have 3 x 21 hour support worker posts vacant, which have been advertised for. Staff from another home that has temporarily closed due to extensive flooding have been covering the vacant hours. The staff have been at the home and working with the service users for a considerable length of time, this ensures continuity and consistency of staff
DS0000062728.V346554.R01.S.doc Version 5.2 Page 23 and approach with service users and it was evident from observation that the staff team knew what the service user needs were and how to meet them. The rota evidenced that there are usually 4 staff on duty in a morning and 3 on the afternoon. In addition staff have the responsibility of cleaning bedrooms, bathrooms and all communal areas, the preparation, cooking and serving and cleaning up after 3 meals per day, supporting service user to attend appointments, activities, undertake shopping and gardening and in addition to this attend to the care needs of service users. Three staff files were examined in the course of the inspection. All had completed application forms, had 2 satisfactory references and CRB clearances prior to commencing employment. All of the staff had completed their basic induction on commencement in their posts. There was evidence that supervision sessions were being held regularly and in addition to this staff meetings were held regularly. However due to the manager being away from the home last year none of the staff had had an annual appraisal and they had not yet been completed for this year, this must be addressed. The home had a training plan and the manager and 1 x senior support worker has completed the NVQ level 4 and the Registered managers Award, the other senior support worker has NVQ level 3 and 10 x support workers have NVQ level 2. This is an excellent achievement. All staff were up to date with their mandatory training and in addition to this service specific training has been provided which included;- postural management, autism, the administration of rectal diazepam and buccle midazalan, values and attitudes, NVCI and positive interaction therapies provided by the speech and language therapist. Staff had completed safeguarding adults training. Two relatives in a survey commented that they did not feel that the staffing ratios were sufficient to meet the needs of all the ladies in the house and that staffing should be provided on 1:1 basis however this was not evidenced during the course of the inspection, staffing appeared to be adequate to meet the needs of service users. The manager should discuss these concerns with relatives and placing authorities to ascertain if funding arrangements and staff provided is adequate to meet the needs of service users. DS0000062728.V346554.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a home that is well run and managed by a competent manager. EVIDENCE: Bethia Cottage is part of Milbury Care Services which is a national provider of care and support services for people with a learning disability. Milbury is part of the Paragon Health Care group, which is a UK wide organisation that specialises in providing a range of services to vulnerable people. DS0000062728.V346554.R01.S.doc Version 5.2 Page 25 The registered manager of the service has a total of 20 years experience in the caring profession, 7 years with older people and 13 years in the field of learning disabilities, she has been a manager for about 8 years, 3 years with Milbury Care. She has completed the NVQ level 4 and registered managers award and is registered with the CSCI. As part of the inspection maintenance records were examined and were up to date. Milbury Care Services have a QA system, which includes regular audits and monitoring of the service and consulting with service users, relatives and stakeholders and culminating in an annual service review. The area manager undertakes regulation 26 visit on a monthly basis, this and the QA monitoring and checking process has highlighted the areas for improvement and the CSCI are satisfied that the home will make progress to ensure all requirements are met within the timescales specified. DS0000062728.V346554.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 x 5 3 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 x 26 x 27 x 28 x 29 2 30 3 STAFFING Standard No Score 31 x 32 4 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 x 3 3 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 3 x x 3 x DS0000062728.V346554.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement The registered person must ensure that service users care is reviewed on at least a six monthly basis. The registered must ensure that where service users display behaviours that are difficult to manage or there are any limitations or restrictions on facilities, choice or human rights to prevent self harm or abuse or harm to others that this is agreed by a multi agency meeting and documented appropriately. The registered person must ensure that health screening is undertaken, health action plans produced and records of outcomes are kept to ensure that service users health needs are identified, planned for and met. The registered person must ensure that where medications are administered PRN that guidelines for administration are written up and followed by staff.
DS0000062728.V346554.R01.S.doc Timescale for action 31/10/07 2 YA7 13 (6 and 7) 31/08/07 3 YA19 13 (1) 31/10/07 4 YA20 13 and 15 31/08/07 Version 5.2 Page 28 5 YA20 13 and 15 6 7 YA29 YA24 23 23 8 YA35 18 The registered person must ensure that staff are competent in the administration of medication by undertaking a competency assessment and retaining a written record. The registered person must ensure that the bath in the en suite bathroom is repaired. The registered person must ensure that there is a maintenance and renewal plan for the home and repairs and redecoration are attended to in a timely manner. The registered person must ensure that all staff have an individual training and development profile and that annual appraisals are provided. 31/08/07 30/10/07 30/10/07 31/08/07 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 2 3 Refer to Standard YA6 YA24 YA33 Good Practice Recommendations The registered person should ensure that all service users plans include detail of service users diverse needs (specifically religious and cultural needs) The registered person should ensure the overgrown field is kept neat and tidy. The registered person should discuss relatives concerns re staffing levels with relatives and placing local authorities to ascertain if the funding arrangements and that staff provided is adequate to meet the needs of service users. DS0000062728.V346554.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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
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