Inspection on 23/05/06 for Ca Na Gardens

This inspection was carried out on 23rd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ca Na Gardens 17/11/09

Ca Na Gardens 28/04/09

Ca Na Gardens 18/12/08

Ca Na Gardens 27/11/08

Ca Na Gardens 29/04/08

Ca Na Gardens 23/05/07

Ca Na Gardens 19/09/05

Ca Na Gardens 16/05/05

Ca Na Gardens 08/10/04

Ca Na Gardens 07/05/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Ca Na Gardens 174 Scraptoft Lane Leicester Leicestershire LE5 1HX Lead Inspector Mrs Kathy Jones Unannounced Inspection 23rd May 2006 08:00 DS0000006360.V296334.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 DS0000006360.V296334.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. DS0000006360.V296334.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ca Na Gardens Address 174 Scraptoft Lane Leicester Leicestershire LE5 1HX 0116 2413337 0116 2433639 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) Hamra Associates Limited Mr Ray McLaughlan Care Home 8 Category(ies) of Learning disability (8) registration, with number of places DS0000006360.V296334.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 19th September 2005 Brief Description of the Service: Cana Gardens is a care home providing personal care and accommodation for up to eight people with a learning disability Hamra Associates Ltd owns the home. The responsible individual for the company is Mr Ray Mc Laughlan who is also the registered manager. The home is located on the outskirts of Leicester city centre and is a detached house, which is indistinguishable from other large family houses in the area. There are a variety of local community facilities, including a large supermarket, small local shops, health centres, temples and churches and takeaways. Other facilities are easily accessible by public transport for example the swimming pool that is 5mins away by bus. Communal facilities include a lounge and a separate lounge/dining area both with patio doors leading onto the rear garden. The home has a very large garden with mature planting, which is accessible to residents. There are seven bedrooms, six single and one shared. Bedrooms are located on the ground and first floor. The home has a shower room and separate toilet on the ground floor, and a bathroom incorporating a bath and shower on the first floor, and a separate toilet. The following information about fees was provided by the registered manager as being current on 23 May 2006: Fees per week range between £326 and £339. Additional charges are made for staffing costs for one to one time. The fees include personal care, accommodation and meals. Additional charges include toiletries, CD’s clothing, transport and holidays. There is also an expectation that residents will pay a proportion of the staff costs for holidays. DS0000006360.V296334.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. All standards identified as ‘key’ standards and highlighted through the report were inspected. These standards are those considered by the Commission to have a particular impact on outcomes for residents. This was achieved through review of existing evidence, pre-inspection planning, an unannounced inspection visit to the home, telephone conversations with the deputy manager following the inspection and drawing together all of the evidence gathered. The review of evidence and pre-inspection planning was carried out over the period of half a day and involved reviewing the reports of the inspections carried out in May 2005 and September 2005, reviewing the service history which details all contact with the home including notifications of events reported by the home and telephone calls received. The information gathered assisted with planning the particular areas to be inspected during the visit. Between the statutory inspection carried out in September 2005 and this inspection two additional inspection visits were carried out to monitor compliance with previous requirements. Compliance with the requirements was achieved in February 2006. This unannounced inspection visit covered the morning and afternoon of a weekday. The majority of residents have no or very limited communication, one resident chose not to talk to the inspector, two residents were happy to show the inspector their rooms. Observations of residents’ daily routines and interactions between them and staff were made. Residents care records were reviewed to check how residents’ care and health needs were being assessed and how their care was planned and supported. A sample of staff records were viewed to check the adequacy of the recruitment process. The inspector talked to staff on duty to establish routines and to discuss the care provided. Feedback on the inspection findings was given to the registered manager and the deputy manager throughout the inspection visit. Following the inspection telephone conversations have taken place with the deputy manager to gather further information, to clarify issues and confirm actions taken. DS0000006360.V296334.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: DS0000006360.V296334.R01.S.doc Version 5.2 Page 7 More detailed care plans are needed which include specific guidance for staff as to the actions required of them to meet residents’ needs and goals. For example it was identified that there was a need to improve a resident’s feeling of control and build self esteem and confidence but there was nothing to indicate how this was to be done. Work needs to continue with the help of the speech therapist to identify ways of increasing choices and decision making and interactions with staff for those residents with no verbal communication or verbal communication, which is not easily understood. Risk assessments need improving as they do not include all known risks such as challenging behaviour and in some cases restrictive measures are put in place without a comprehensive risk assessment, which considers other options to minimise risk. Care plans and records should be developed to demonstrate that resident’s interests, choices and goals form the basis for the provision of activities and meals. Information about residents’ cultural and religious needs must be carefully checked to ensure that they are properly respected. A care plan provided by social services identified that a resident should have Halal meat however staff understanding was that although they may have it sometimes it was only if requested. There was insufficient information to ascertain the seriousness of incidents where a resident had hit another resident in the records and as a result the deputy manager has confirmed he will implement a more detailed incident record and screen them to check if there is a necessity to refer through protection of vulnerable adult procedures. Areas of the home were in need of re-decoration, refurbishment and a thorough cleaning programme. Staff training needs to be particularly focussed on working with adults with a learning disability. The need for staff to have training in challenging behaviour was also identified. Implementation of a comprehensive quality assurance programme is seen as being important in ensuring good outcomes for residents’. 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. DS0000006360.V296334.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 DS0000006360.V296334.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. The admission process establishes the homes ability to meet the needs of people admitted to the home prior to admission. EVIDENCE: No new residents have been admitted to the home since the last inspection and there are no vacancies. The registered manager confirmed that prior to a new resident being admitted an assessment of their needs would be carried out. A prospective resident would visit the home several times and then consideration would be given as to whether the home could meet their needs. The homes statement of purpose states that, the home caters for people with learning disabilities from low to high dependence. In order to provide prospective residents and their representatives with clear information about the needs that can be met, advice is given to include more detail about the range of needs and types of learning disability the home is able to meet DS0000006360.V296334.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. While it is acknowledged that improvements are being made the current shortfalls in the planning of care and risk assessments have the potential to put residents’ at risk of not having their needs fully met. EVIDENCE: Review of a sample of residents’ care records showed that work had been carried out to identify their needs and relevant information from health professionals such as a psychologist was available. Advice was given to develop more detailed care plans which give staff specific guidance as to the actions required of them to fully meet residents’ needs and goals. For example a psychology report identified the need to improve a resident’s feeling of control and build self esteem and confidence. There was no evidence of an effective care plan to achieve this. DS0000006360.V296334.R01.S.doc Version 5.2 Page 11 There was written guidance available for staff on how to deal with a resident’s unacceptable behaviour however the incident records in place did not give enough detail about the events that occurred, led up to them or how they were actually dealt with to allow for proper monitoring of the effectiveness of the plan. The majority of residents’ have no or little verbal communication. Observations of the morning routine identified that the majority of interactions between staff and residents with no verbal communication was task based. Referrals have been made to a speech and language therapist to establish and advise staff on appropriate methods of communication. Staff have been working with residents to identify their preferences, for example pictures of some foods had been cut out of magazines and showed likes and dislikes. This is an area to be developed with advice from the speech and language therapist, to where possible, increase opportunities for choice and decision making. The inspector was informed that the first language of all residents is English and the second language for some residents is Gujarati. During the inspection interactions between residents’ and staff were in English however some staff working in the home speak Gujarati and provide one resident who has good verbal communication opportunities to communicate in Gujerati. One resident manages his own finances. Risk assessments are in place however it was identified that the risk assessment documents do not incorporate all known risks such as challenging behaviour, which presents a risk to other residents’ and staff. As identified in the following section of this report consideration of a variety of measures to minimise risk must be given to ensure that residents’ rights are not restricted unnecessarily. DS0000006360.V296334.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. The lack of planning and clear records makes it difficult to confirm that residents are receiving appropriate stimulation and that their religious needs are fully respected. EVIDENCE: One resident by agreement has day care services/activities provided by the home. The majority of other residents’ access various day care services/activities arranged by social services. Arrangements are in the process of being negotiated with social services for one resident who has been without any planned activity for a year to receive some external day services. It was highlighted during the staff meeting that this was a problem they had been trying to resolve with social services for some time and that this would now allow better planning of activities for the other resident. DS0000006360.V296334.R01.S.doc Version 5.2 Page 13 The inspector was advised that at present activities, community access etc are not pre-planned and decisions about what to do are made on the day. There were no recent records showing how residents had spent their day or the frequency of activities. One resident’s profile had not been completed since 28 March 2006. On the day of the inspection five residents’ were out at day care services while three were at home. During the morning two residents’ sat in on the staff meeting while another chose to dust and tidy her room. Routines of the home for example times for getting up are based on residents’ individual programmes. On the morning of the inspection residents’ ate breakfast in the kitchen as and when they got up, chatting to staff as it was served. Practice is to treat residents’ rooms as their private space; this was confirmed by a resident telling the inspector that he didn’t want her to see his room and another saying that he wasn’t allowed to go into other residents’ bedrooms. Residents’ have unrestricted access to the lounge, dining room and garden. Meals are eaten in either the dining room or the kitchen. It was identified that at other times residents’ are unable to access the kitchen due to it being kept locked. Discussion with the deputy manager about this restriction identified that this practice had come about partly due to risks such as sharp knives and cleaning products, which are in unlocked cupboards and drawers and partly due to some advice they had received about fire safety. Advice has been given to check any requirements with the fire officer. There were no risk assessments in place to demonstrate why residents were not able to have free access to the kitchen. Records and discussion confirmed that residents’ are encouraged and supported in maintaining contact with their relatives. A resident said that the food was good. There are no pre-planned menus in place and decisions about meals are made on a day to day basis. Staff advised that residents’ who are able to communicate their views verbally are consulted about meals though there is no system currently in place to consult with others. The inspector was told that residents’ cultural and religious needs are taken into account when providing meals however some of the information was not clear. For example a social services care plan identified that a resident was to have Halal meat however staff understanding was that although they may have it sometimes it was only if requested. Advice has been given to ensure this is clarified and clearly identified within the care plan. Residents’ weight is monitored and the need to closely monitor two residents who had been identified as losing weight was re-iterated to staff during the staff meeting. DS0000006360.V296334.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 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 is good. This judgement has been made using all the available evidence including a visit to the service. Residents receive a good level of care and support, medication is well managed and health care services are accessed as required. EVIDENCE: Staff were aware of the individual support needs of residents’ and care records identified those residents’ that were independent in the management of their personal care. During discussion with the deputy manager about care plans he confirmed that it was his intention when revising the care plans to identify areas where residents’ could be encouraged and supported to become more independent. There was evidence from staff and the registered manager that peoples’ health is monitored and appropriate referrals to health care professionals are made. Medication was securely stored. Excessive stocks of medication are not kept and generally medication appears to be well managed. The registered manager advised that the pharmacist visits the home twice a year to check how the medication is managed and is available for any necessary advice. DS0000006360.V296334.R01.S.doc Version 5.2 Page 15 Some medication is given as and when required. Advice was given to record any tablets carried forward to the next month to ensure an accurate stock check can be made. DS0000006360.V296334.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. Procedures are in place to deal with concerns and staff are aware of their roles in protecting residents’. EVIDENCE: The Commission for Social Care Inspection have received no complaints about the service since the last inspection. The home has a complaints procedure, which has been revised to include all the relevant information following the last statutory inspection in September 2005. Staff had no concerns about how residents’ were being cared for or treated in the home. They were clear about their responsibilities to report any concerns that they may have and responsibilities for acting to safeguard residents. There is an adult protection procedure, which identifies the actions, to be taken to report a concern and staff were aware of the policy. It was identified that there had been occasions where a resident had hit another resident however the records provided insufficient information to ascertain the seriousness of the incident. Following the inspection and prior to the production of the report the deputy manager has informed the inspector that he is implementing a more detailed incident record and will be screening them all to check if there is a necessity to refer through protection of vulnerable adult procedures. DS0000006360.V296334.R01.S.doc Version 5.2 Page 17 The management of residents’ finances was not reviewed during this inspection, as records were not available. The registered manager advised that this was because the procedure is in the process of being altered and records will normally be available. At present one resident has their own bank account however all other residents’ monies are held in one current bank account, which does not accrue any interest. Advice was given to look at the possibility of residents’ having their own individual accounts which even if they were not able to access them without support would attract some interest for them. DS0000006360.V296334.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. Residents have a comfortable and homely place to live, which will be improved by the planned re-decoration, refurbishment and more thorough cleaning processes. EVIDENCE: The home is a large detached house on the outskirts of the city centre. It is indistinguishable from other large houses in the area. There is a lounge and a lounge/dining room on the ground floor both of which provide access to a large garden. Residents’ were observed to access the garden freely throughout the inspection. It provides some quiet space and has a large trampoline Two residents showed the inspector their rooms during the inspection. One resident had been dusting her room that morning and said that she keeps it clean and tidy with assistance from staff who do the hoovering. The resident confirmed that she was happy with the room and can access it as and when DS0000006360.V296334.R01.S.doc Version 5.2 Page 19 she wishes. The other resident’s bedroom seen had a wardrobe door missing, it was identified that this had been missing for some time and had not been replaced due to the damage being caused by the resident. However the registered manager advised that he was in the process of sourcing a sturdier wardrobe. A sample check of the premises identified that it is showing signs of wear and tear. The registered manager informed staff during the staff meeting that maintenance and re-decoration of the premises would be carried out while residents are on holiday. The deputy manager will arrange a full review of the premises identifying any required works including work that may need to be done prior to the holiday at the end of August. The casing on the central heating boiler is in poor condition and held together with sellotape. Evidence that it had been serviced could not be located during the inspection, however the deputy manager is arranging for it to be serviced and has advised that he will forward a copy of the certificate to The Commission for Social Care Inspection as confirmation. The home was generally tidy and there were no unpleasant odours however more thorough cleaning is required. Some areas were pointed out to the registered manager during the inspection including the staff toilet where the edges of the floor were dirty. Handwashing facilities consisted of a bar of soap, which was cracked and ingrained with dirt and a few paper towels on a dusty windowsill. DS0000006360.V296334.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. Residents’ have carers’ who are from a variety of backgrounds and cultures, which match theirs. However additional training for staff in learning disability and challenging behaviour would enable their needs to be more fully met. EVIDENCE: The homes statement of purpose states that sixty seven percent of staff have a National Vocational Qualification (NVQ) at level 2. Staff confirmed that there has been a programme of training in the home, which included NVQ training, giving staff a basic understanding of care practices. The majority of staff have experience of working with people with a learning disability either at Cana Gardens or in previous employment. Although the deputy manager said that staff had attended an external induction and foundation course to give them knowledge of basic care practices. Neither this training nor the NVQ training was part of the Learning Disability Award Framework (LDAF) training which specifically focusses on working with adults with a learning disability. DS0000006360.V296334.R01.S.doc Version 5.2 Page 21 Discussion with staff and a sample check of records confirm that staff receive one to one supervision sessions which provide opportunities to identify if any additional training needs are required for them to meet the needs of residents. It was also positive that during the staff meeting they were discussing additional training needs, which included challenging behaviour training to meet the specific needs of a resident. Staff confirmed that various training courses have been held including medication training and first aid. The staff team consists of people from a variety of backgrounds, cultures with a mixture of experiences and linguistic skills. For example there are some staff that speak Gujarati, which is the second language of some of the residents’. One member of staff has the same religion as a resident and takes him to the temple if a family member is not available. A sample check of records for two recently recruited staff confirmed that references and criminal record bureau clearances are received prior to staff working in the home. DS0000006360.V296334.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. While areas for improvement have been identified action is being taken to improve outcomes for residents’. EVIDENCE: The inspector was told that the registered manager is taking a lesser role in the day to day management of the home. The day to day management of the home at the time of the inspection was being carried out by the deputy manager with support from the registered manager. The registered manager will remain as responsible individual and will still have responsibility for reviewing standards of care provided to residents. However an application for registration as manager has been completed by the deputy manager and was about to be submitted to The Commission for Social Care Inspection. The deputy manager has undertaken NVQ 4 in management in preparation for his application for registration. DS0000006360.V296334.R01.S.doc Version 5.2 Page 23 Two additional inspection visits took place following the inspection carried out in September 2005 to monitor compliance with requirements made. Action had been taken to address the issues raised and compliance was achieved. From discussions during the inspection and in telephone calls following the inspection the deputy manager has expressed a commitment to acting on the advice given. For example the day following the inspection the inspector was informed that work had started on improving incident recording and residents’ care plans in order to improve the support, care and protection provided to residents’. Some elements of a quality assurance process are in place as for example questionnaires are sent out to relatives periodically. There is a policy dated 2003, which talks about consideration of implementation of a policy however there is not yet a programme in place for carrying out a thorough review of the standard of care and services which residents receive. Review of previous inspection reports identifies that action is taken in respect of requirements made however standards of care cannot be reliant on the inspection process and the implementation of a comprehensive quality assurance programme is seen as being important in ensuring good outcomes for residents’. Health and safety training was being offered to staff at the staff meeting and it was confirmed that staff have recently had other training to help protect the health and safety of residents’ including first aid. A sample check of fire records confirmed that equipment is being checked on a regular basis and fire drill carried out. The deputy manager is to collate records relating to any regular servicing or maintenance requirements to ensure that these are all up to date and risk to residents’ is minimised. DS0000006360.V296334.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X DS0000006360.V296334.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 12 (1) (a & b), 12 (2) Requirement Care plans must be reflective of residents’ current needs and provide staff with clear instruction as to the actions and progression required. Timescale for action 30/07/06 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. 2. 3. Refer to Standard YA9 YA6 YA9 YA9 YA16 4. 5. YA13 YA17 Good Practice Recommendations Risk assessments need to include all identified risks including challenging behaviour. Care plans must include agreed goals and demonstrate how decisions are made. The use of the keypad restricting residents’ access to the kitchen should be reviewed and all other options for minimising risk considered. Activities and community access should be planned and based on residents’ preferences, identified needs and goals. Conflicting information relating to the provision of Halal meat to meet a resident’s religious needs should be DS0000006360.V296334.R01.S.doc Version 5.2 Page 26 6. YA24 YA30 YA35 YA32 YA39 checked with the author of the social services care plan and relatives. A thorough review of the re-decoration, refurbishment, maintenance needs and cleaning programmes should be carried out and action taken to address shortfalls. Staff should receive training specifically for working with adults with a learning disability and training on strategies for dealing with challenging behaviour. An effective quality assurance programme to identify areas where residents’ lives and care can be improved should be implemented. 7. 8. DS0000006360.V296334.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000006360.V296334.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. 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