Inspection on 16/08/06 for Carisbrooke

This inspection was carried out on 16th August 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

Carisbrooke 15/09/08

Carisbrooke 20/09/07

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Carisbrooke 35 Welholme Road Grimsby North East Lincs DN32 0DR Lead Inspector Janet Lamb Unannounced Key Inspection 16th August 2006 13:00 DS0000067528.V308480.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 DS0000067528.V308480.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. DS0000067528.V308480.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carisbrooke Address 35 Welholme Road Grimsby North East Lincs DN32 0DR 01472 354434 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) Diamond Care (2000) Limited Dean Smith Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (12) of places DS0000067528.V308480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 07/03/06 Brief Description of the Service: Carisbrooke is a residential care home in a busy area of Grimsby. The property is a large Victorian house, with car parking for three cars to the side. DS0000067528.V308480.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began with the sending of a pre-inspection questionnaire to the home in early June 2006, requesting information on the service provided and the names of those service users living there, as well as the names and addresses of their relatives and any health care professionals involved in their care. Survey comment cards were then issued to as many of these people as possible, including service users, to obtain their views and opinions of the care provided within the service. Then on the 16th August 2006 Janet Lamb visited Carisbrooke, without prior warning and as part of this inspection. Almost all of the service users were spoken to and three were interviewed, but most of them were observed throughout the inspection. The Manager and one senior care officer were interviewed, and another two carers were briefly spoken to determine their views. The main parts of the house were inspected, as were all of the service users’ bedrooms. Care plans, risk assessment documents and some records were read and staff files and training records were seen. All personal and private areas and documents were only seen with the permission of the people they belonged to. What the service does well: Service users are well assessed before they take up residence in the home and information about their assessment of needs is put into a working care plan. Service users enjoy making many choices in their lives and are provided with whatever support is necessary to make those choices. Service users are encouraged to take risks as part of their independent lifestyle. Service users enjoy a variety of pastimes in the home and the community that are appropriate to their ability and preference, and they lead fulfilling lives in respect of the activities they do and the relationships they have. Their rights are fully upheld and they experience a high level of respect. All service users enjoy a varied and nutritious diet that they assist to devise. Service users receive a good level of personal support when necessary and in a manner, which meets their preferences. Their physical and emotional needs are well met. They have opportunities to give their own medication if they wish and are capable. Service users’ views and complaints are listened to and acted on if possible, and they are well protected from self-harm or abuse. DS0000067528.V308480.R01.S.doc Version 5.2 Page 6 Service users live in a safe, homely and comfortable environment that is also clean and hygienic. Service users are cared for by a sufficient number of competent and welltrained staff, although a few more of them could complete the recommended qualifications. Staff are well recruited and so service users are well protected from undesired workers. Service users benefit from a consistently well-run service of care that considers their interests, their views and their wishes as part of the monitoring, reviewing and development of the home. Service users and staff benefit from good systems and checks for securing their health, safety and welfare. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000067528.V308480.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000067528.V308480.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 only. 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 have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. EVIDENCE: One new service user admitted to the home since the last inspection was asked if the Inspector could look at documents relating to their placement in the home. Permission was given. The service user could remember someone from the council actually completing an assessment for his care, and was fully aware of the documentation held in the care plan generated from the assessment. A copy of the assessment was not available in the service users case file and it was believed relatives may have been in possession of it. The Manager resolved to locate a copy and ensure one was held in the home. The service user’s file contained a combined assessment and care plan document completed by staff at Carisbrooke. This service user had been given a good introduction to the home, staff and other service users and had spent time visiting and having tea before starting DS0000067528.V308480.R01.S.doc Version 5.2 Page 9 a trial period. This was documented in diary notes started before the actual placement began, and was confirmed by the service user during conversation. Two longer residing service users were also asked if their documents could be seen and also gave their permission. They had their council assessments held in files as well as the ones done by the home. There was evidence in assessment documents that service users and family representatives had been involved in the process. Because the home is now in the ownership of new providers, the statement of purpose and service user guide are out of date, but only in respect of owner details. The new Manager acknowledged that these documents needed updating and putting into a suitable format for the service users in the home. He stated that the documents should be revised within the next three months. DS0000067528.V308480.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 and 9. 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 have good care plans that enable them to be independent and to make choices. Service users enjoy making their own decisions in life, with risk assessments being put into place where necessary. EVIDENCE: Permission was obtained from service users to inspect their care plans and related documents, and these showed the areas of need for action. Evidence was seen in diary notes of decisions and choices made by service users and of the care they receive, which corresponded to the care plans. Restrictions on freedom and choice imposed by specialist programmes are not necessary, although some service users have prescriptive care plans for safety and going out of the building. Staff constantly maintain service users state of involvement with one another by including them in conversations, seeking their opinions and asking them questions about their day etc. Staff provide information on community life and offer choices, which are often taken up. One service user has a job doing DS0000067528.V308480.R01.S.doc Version 5.2 Page 11 outdoor work and at least six others attend day services where they interact with friends and acquaintances, or engage in activities. Service users were keen to talk about their day, comments being “I’ve been to the centre, but my transport won’t be there on Friday. I can take a taxi or have the day off if I like. I shall take the day off. I like going shopping,” or “I like this music, don’t you?” and “I want to wash my hair tonight. What’s for tea? I’m going to Mablethorpe at the weekend, do you like Mablethorpe?” Service users were observed interacting very well and making their needs easily known. Staff were observed responding to needs in a timely fashion and to service users’ satisfaction. Most of the service users handle the personal allowance element of their finances, and some have family members that deal with main issues. Information obtained from the home before the visit states there is only one service user that fully handles their own finances, while seven have the Manager as appointee. Service users spoken to were satisfied with the financial arrangements within the home. Several have managed to save some money to pay for a holiday to Centre Parks, Nottingham this year and will be going away in September. There is only one who struggles to maintain a good level of personal income. They will be taking a weekend break away with some of the service users that are less mobile. Financial records were not seen on this visit. All activities, pastimes and actions that involve risk are subject to a written risk assessment maintained within care plans. Staff are vigilant about safety and generally maintain a safe environment and have safe practices. Service users risks of injury etc. are reduced wherever possible and they have learned over the years to avoid the dangerous. All either use arranged transport when going out or some take a taxi. There is a written missing persons procedure, but service users have very good routines, know when and where they should be and do not usually wander. DS0000067528.V308480.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 and 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. All service users enjoy satisfying lifestyles of their choosing, with support from staff where necessary. EVIDENCE: Service users spoken to are very satisfied with the lifestyles they lead. One has a job in the community, but also enjoys helping with tasks around the home. During the visit he spent some time trimming hedges to the front of the house. “I like gardening, I’m going to do some out the back later. I used to be a dustman,” was what he said. The Manager later paid him for his work. Other service users attend day care services, at different establishments belonging to the social services or voluntary groups. They use arranged transport and have set days to attend. Almost everyone was seen and spoken to on their return at the end of the day and they are presented as being content and happy with their arrangements. DS0000067528.V308480.R01.S.doc Version 5.2 Page 13 One service user said, “I’m going shopping for some shoes and a bag, I like shoes. My mum gave me this jumper.” Another service user spoken to was unable to work due to poor mobility, and did not attend day services, but he was quite happy with the opportunities available to go for a visit to the park across the road from the home. On being asked about his care plan and whether or not he would like to make any changes in his life he said, “It’s a good idea to have a care plan, staff follow it. I’ll think about that one.” He also said,” I like to watch television, listen to music and see my family. I can decide when I go to bed, but not always because I don’t like to be in bed too late.” All service users take part in community activities appropriate to their mobility. Usually they go out in twos or threes to the pub, to go shopping, or to visit the cinema etc. but occasionally they go out as a group and recently had a meal out in a Chinese restaurant. Everyone dressed up for the occasion and the event was successful. This was spoken about with satisfaction and information was seen on activity records and in diary notes. All but one service user has family and friend contact. Only positive information was seen on relative comment cards, with relatives stating they are very happy with the care service users receive. One service user went to a relative’s for tea on the day of the visit, as usual on Wednesdays. Another spends time with a different sister each weekend, while one is very close to her mother and another has a sister and brother-in-law that visit and takes him out. Everyone enjoys a full and satisfying lifestyle. Service users can have a key to their room if they request it and if they are risk assessed for safety and security, but only one actually does hold a key. Another service user said he would think about having one. Service users were observed asking for a hot or cold drink at all times of the day, and those able to, helped themselves. They discussed what they like to eat. Staff explained that service users have made likes and dislikes known to them over the years and when preparing meals know what they will or will not try. Menus are compiled according to healthy options and a main meal is provided at lunchtime to those not at work or centres. Tea is a lighter meal. Service users spoken to do not make any adverse comments about food provision, and two said, “the food is alright,” while another asked, “what’s for tea? Sandwiches and salad, I want ham sandwiches.” No one expressed any burning desires to eat other than what is provided for them. The home keeps a menu book to show what service users have eaten and their daily diary notes record where they have been, what they have done etc. DS0000067528.V308480.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 and 20. 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 enjoy a good level of support with their health care and personal care, and with administration of their medicines. EVIDENCE: All service users have ‘health action plans’ recorded within their care plans to show how health care needs are to be met and to record when and by whom a visit has been made. They have nutritional risk assessment documents and dependency profile assessments, which show improvement or deterioration in graph format as well as written format, within care files. Staff provide advice and support to service users on health related issues, and encourage them to be responsible for their safety and welfare. The Manager and staff provided verbal information on individual service users’ health needs and how they are met, which was then verified within care plans and diary notes. Service users spoken to also confirmed they are given advice and information and helped to make decisions if necessary about health problems. One service user said, “If I get poorly I would go to hospital. I always get my medicines DS0000067528.V308480.R01.S.doc Version 5.2 Page 15 and I am happy with the way things are done.” Another said “I’ve been well for a long time now.” Staff explained about the wearing of an SOS bracelet, and that an upset with medication a few weeks ago had resulted in the latter service user suffering a seizure, the first in two years. A staff member was appropriately disciplined and demoted, and all staff were then re-checked for their competence in medication administration. Staff training records showed staff are trained to administer drugs competently, although three of them did not actually complete the exam at the end of the 12-week course. The Manager has recently supervised and checked these three staff to determine their competence. Other staff have been spot checked while giving out medicines. There are no service users that self-medicate and those spoken to were of the opinion that medicines are best held locked away and did not want the responsibility of looking after theirs. One said, “I’ll think about that one,” when asked if he’d like to self-medicate. He went on to explain what his medication is for and how often it needs taking. Understanding and competence varies amongst the service user group, but they are satisfied with the way their personal and health care needs are met. Records seen on medication administration were well maintained and reflected a robust audit trail. DS0000067528.V308480.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): 22 and 23. Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Service users, and their relatives, have access to robust complaint and protection systems within the home and are confident their concerns will be dealt with appropriately and any fears of harm or neglect will be detected. EVIDENCE: Service users spoken to were of the view that life at Carisbrooke is very good and offers plenty of opportunity to lead a fulfilling lifestyle. The care and support they receive is of a high standard and therefore there is never any need to complain or grumble. Service users could not remember ever making a complaint and when asked if they knew what to do to express a concern or worry one said, “I would have to get hold of someone,” and indicated the staff member in the room. Another said, “I would see… ,” and named one of the staff. Service users clearly have confidence in the staff that care for them and know their problems or worries will be sorted. There is a complaint policy and procedure available in the home and within the statement of purpose, and staff understand the action they must take if anyone does have a complaint to make. There have been no complaints made to the CSCI or to the provider in the last twelve months. Relative comment cards received showed everyone is aware of the complaint procedure, but no one has ever had to make a complaint. DS0000067528.V308480.R01.S.doc Version 5.2 Page 17 The same situation applies to the handling of allegations and the protection systems within the home to prevent service users being abused or neglected. Management, staff and service users know they have a means of informing the right people to deal with any situation. Staff have received vulnerable adult training and this was evidenced in their training files. The Manager has also done this training as well as training on equality and diversity, and there is a very open and honest approach within the staff group, which allows all service users to speak their minds. Staff constantly seek service users opinions of the support they receive, on the activities they take part in, and on any subject that happens to come into the conversation. This is always done in a very inclusive and respectful way, affording service users dignity and a sense of value. Neither of these systems have been tested thoroughly or recently and there are no records of complaints or vulnerable adult allegations, but this, and the openness experienced amongst the service users and staff, is a testament to the fact that life in the home is good, relaxed and as service users wish it to be. They are all very contented and there are no occasions or situations that arise to make any of them complain or seek protection. DS0000067528.V308480.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 and 30. 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 enjoy a good level of cleanliness and hygiene within the home and the fabric of the building is well maintained. EVIDENCE: Permission to view bedrooms was given by those service users spoken to, and bedrooms proved to be highly personalised, very clean and comfortable, and a place where service users could enjoy their privacy. Although four of the eight rooms are doubles, they are fitted with good partitioning dividers to offer separate areas for each service user. The home is a safe environment, well maintained, and meets service users individual and collective needs as a domestic dwelling that is very much their home. Wheelchair access is available to the front and the house has an internal ramp to the rear. Fire and environmental health requirements are met. The laundry is domestic in style and equipment, being relatively new, meets the Water Supply (Water Fittings) Regulations 1999. Some minor repairs are DS0000067528.V308480.R01.S.doc Version 5.2 Page 19 needed to the floor surface in the laundry. The kitchen also requires minor repairs to the cupboard doors and would benefit some modernisation, but in general the kitchen is clean and functional. Staff have completed infection control training and practice in maintaining cleanliness and preventing spread of infection is very good. Training records, copy certificates and observation evidenced this. Personal protective equipment was seen in use and staff follow good food hygiene procedures and policies. The Manager is putting together a new training programme to ensure all staff receive the updated training they may need. Standards 24 and 30 are both fully met. DS0000067528.V308480.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, 33, 34 and 35. 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 benefit from good recruitment and selection of care staff and from a well-trained staff group, in respect of mandatory training. Service users would benefit more from a higher percentage than 30 of care staff holding the appropriate NVQ qualifications. EVIDENCE: There is a recruitment and selection policy and procedure in place, and staff files show information required under schedule 2 is held. Any such information belonging to staff from the new provider company, that is not available, is held at the company headquarters. One staff that did not have evidence of a criminal records bureau check and references for the job at Carisbrooke, was working there under checks and references obtained for another establishment in the company. These or evidence of their existence, need to be held at the home. There are no service users involved in the recruitment and selection of new staff. The information obtained from the pre-inspection questionnaire, viewing certificate copies in staff files and discussion with the Manager and staff DS0000067528.V308480.R01.S.doc Version 5.2 Page 21 showed there are some staff with the necessary qualifications at NVQ level, but only numbering three from ten and giving 33 of the care staff. This decrease has arisen due to one staff leaving and two being taken on. Therefore a concerted push is needed to get more staff onto and completing the qualification. Staffing hours are appropriate for service users’ levels of dependency, the Residential Forum hours having been calculated. There are always two staff in the home during the day, and one waking and one on call at night. The Manager sometimes works supernumerary and sometimes as the second staff on duty. Staff training and development is currently being assessed by the new Manager, and with the aid of staff knowledge, training records and copy certificates he is compiling a list of all the training that needs updating, refreshing etc. A general training and development plan and individual staff training plans will soon be available. Meanwhile there is sufficient evidence to conclude that staff do complete regular statutory training and do keep up with current trends and developments. Service users are not really interested in staff training activities, but do enjoy listening to conversations. DS0000067528.V308480.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 and 42. 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 benefit from having a Manager that is qualified and registered and that maintains consistency within the service. They have use of a quality assurance system, but what provides them with a more effective means of inclusion is the culture within the home. They enjoy protection from harm under the home’s health and safety measures in place and the practices carried out to maintain service users’ and staff health, safety and welfare. EVIDENCE: There is a new Manager in post, qualified with NVQ level 4 Registered Manager’s Award, and experienced at having managed and supervised staff for more than two years at another establishment within the company. He was observed to relate very well with service users on the day of the visit and they responded very well in return. DS0000067528.V308480.R01.S.doc Version 5.2 Page 23 There is some work to complete to ensure staff are kept up to date with their training, and to ensure supervisions are not missed, as well as to audit some of the communal areas for upgrading and modernising, but generally the Manager’s role, to make sure the home continues to run for the benefit of the service users, is carried out well. A quality assurance system has been in place in the past, and the Manager is used to dealing with such systems, but there needs to be a period of quality assuring the service under the new provider and Manager before a report of any review under schedule 24 is completed and sent to the CSCI. Service users and staff spoken to were aware of the ways in which service users are consulted about their care and the support they receive: reviews and daily consultation being the main ones. Service users were confident they would be listened to and that any suggestions they have would be considered and adopted if possible. Consultation within the home is very much a practical, day-to-day event that was often observed, with service users enjoying making choices and expressing wishes, as they need to. Staff respond positively to requests for support and assistance. Areas listed in standard 42 that were spot-checked include fire safety, maintenance of electrical and gas systems and equipment, food hygiene and maintenance of a safe environment. Fire safety systems are checked and recorded weekly within the home, though there has been a slight hiccup for the last four weeks following the resignation of one staff with specific responsibility to carry out equipment checks. A new staff member is to take up the responsibility imminently. Manufacturers annually check the fire safety equipment, the last one being October 2005. Fire safety drills are held monthly and are recorded. Staff spoke confidently about the procedure and practice for evacuation. Information concerning electric and gas maintenance was unavailable and had to be obtained from the last inspection. This was evidenced via the information seen on the last inspection visit on 07/03/06, and the Manager was requested to seek, obtain and forward confirmation. Staff have completed basic food hygiene courses and practice observed within the home was good. Staff encourage service users to make drinks for themselves and they were observed doing this, but staff prepare all meals for service users and staff. Menu books are kept to record the actual foods consumed by service users. Food hygiene copy certificates are held in staff files, and the Manager is compiling a list of all training that needs updating. The kitchen is clean and hygiene practices are satisfactory. The environment is well maintained and safety of service users and staff is ensured by following the appropriate legislation in relation to moving and DS0000067528.V308480.R01.S.doc Version 5.2 Page 24 handling, fire safety, COSHH, use of personal protective equipment, and recording and reporting of accidents and diseases. Records are maintained for any accident within the home, fire safety equipment checks, water temperatures, kitchen cleaning activities and food temperature on serving, as well as policies and procedures held for staff to adhere to. DS0000067528.V308480.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X DS0000067528.V308480.R01.S.doc Version 5.2 Page 26 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 YA32 Regulation 18(1) Requirement The Registered Provider must provide more staff in the home with the required NVQ qualifications, so that service users can benefit from competent and trained staff. Timescale for action 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA34 Good Practice Recommendations Service users could be involved in the recruitment and selection of new staff. DS0000067528.V308480.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000067528.V308480.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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