Inspection on 19/12/08 for Cherryvale

This inspection was carried out on 19th December 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cherryvale 25/07/07

Cherryvale 16/11/06

Cherryvale 24/02/06

Cherryvale 24/11/05

Cherryvale 15/12/04

Cherryvale 01/06/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

CARE HOME ADULTS 18-65 Cherryvale Cherryvale Acrefield Road Liverpool Merseyside L25 5JN Lead Inspector Ms Lorraine Farrar Unannounced Inspection 19 December 2008 12:30p DS0000025237.V363541.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 DS0000025237.V363541.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. DS0000025237.V363541.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherryvale Address Cherryvale Acrefield Road Liverpool Merseyside L25 5JN 0151 428 4458 F/P 0151 428 4458 No email www.c-i-c.co.uk Community Integrated Care 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) Manager post vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000025237.V363541.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1 The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 3 Date of last inspection 25 July 2007 Brief Description of the Service: Cherryvale is a detached dormer bungalow providing accommodation and support for three adults who have a learning disability. It is based in a residential area of Woolton, with local shops and public transport near by. All of the rooms used by the people living there are on the ground floor. The first floor is used for office and laundry facilities only. Outside there is a well maintained, private garden and patio area, with some off street parking at the front of the bungalow. Various aids and adaptations are provided to support people with their personal care and mobility. There are staff available in the home twenty four hours to support the people living there. The service is operated by Community Integrated Care (CIC) who provide staff, budgets and support. CIC are a national organisation who provide support services to people across the country. It currently costs between £1178.50 and £1268.50 each week to live at Cherryvale. DS0000025237.V363541.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use the service experience adequate quality outcomes. Information for this inspection was gathered in a number of different ways. We visited Cherryvale on 19 December 2008 for a period of 4.20 hours. During this visit we spent time reading records, meeting with the people living there, observing life in the home and looking at the environment. We also talked with three members of staff, including the manager and a senior manager from the organisation. Before we visited we sent the manager a pre inspection questionnaire which she completed and returned to us. This gave us information about how the home operates, any improvements they have made and any plans for future improvements that they have. In addition the form provides information about records, staffing and the overall management of the home . We reviewed any information we have received about Cherryvale since our last big inspection. This information all helped us to plan our site visit and in writing this report. What the service does well: Staff who work at Cherryvale know the people living there well and are able to understand and respond to the different ways they communicate. They have a good understanding of people’s personal care needs and the things they do and do not like doing. People are supported to visit their family and share an adapted mini bus which helps them to get out and about in their community. When they are at home people can spend time engaged in activities that they enjoy either with staff or alone in their room, as they prefer. A clear system is in place for dealing with any concerns or complaints that arise. Information about this is readily available to people living in the home and their relatives. This helps to ensure that any concerns that may arise are listened to and acted upon. Cherryvale is adapted to meet the mobility needs of the people living there. Everyone has their own bedroom, which they can personalise to suit their needs and choices. Sufficient shared space is also available so people can sit with others or spend time in their room as they prefer. DS0000025237.V363541.R01.S.doc Version 5.2 Page 6 Clear recruitment systems are in place for new staff. These help to ensure that staff are suitable to work with people who may be vulnerable. What has improved since the last inspection? What they could do better: People are not always supported to have regular health checks such as with the optician, within the timescales identified in their care plan. This could lead to potential issues with people’s health not being noted and acted upon as quickly as they could be. Risk assessments in people’s care files are not always completed or in place. This could lead to potential risks for the person not being identified and minimised. The temperature of the room where medication is stored is not recorded and monitored. This could lead to medication being not being stored at the correct temperature for it to remain effective. Training for staff is not planned around the support needs of the people living there and staff do not have regular training in all areas of health and safety. This could lead to people not being supported as safely and well as they should be. There has been no registered manager at Cherryvale for some time. As the process of a manager registering with the commission helps to ensure that people are suitably qualified and experienced to operate a care service this could impact on the overall management of the service. A system needs to be out into place to ensure that regular health and safety checks of the building are carried out within the correct timescales. This will help to ensure that Cherryvale is a safe place for people to live, work and visit. DS0000025237.V363541.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000025237.V363541.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 DS0000025237.V363541.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, & 4 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Sufficient information is obtained about and given to people considering moving into Cherryvale. This helps everyone to decide if it is the right place for the person to live. EVIDENCE: Nobody new has moved into Cherryvale for several years. Therefore it is not possible for us to practically assess the support offered to people who may be thinking about living there. There is however, a policy in place from the organisation for supporting people considering moving into the home. This states that a full check of the person’s needs and choices will be carried out with the person and other people who support them, such as their family. People will be offered the opportunity to visit the house, meet with staff and the people living there and stay overnight if they wish. In addition the self assessment form states that if someone does move in, the manager will act as their key worker for the first three months, to support them to settle in. DS0000025237.V363541.R01.S.doc Version 5.2 Page 10 An information brochure about Cherryvale is available to inform people about the services and support they can expect. This uses pictures to enable people to understand the information more easily. This all helps everyone to decide if Cherryvale is the right place for the person to live and helps staff to plan how they will meet the person’s needs and choices. DS0000025237.V363541.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. People’s individual needs and choices are recognised and they are supported by staff to meet them but there are some gaps in the care files that may lead to people’s needs not being met as safely as possible. EVIDENCE: Individual care plans are in place for all of the people living at Cherryvale. The self assessment form states that recent improvements to the plans have included putting Essential Lifestyle Plans (ELP’s) into place for people. We looked at a sample of files and found that these ELP’s had been well completed. They provide clear information for staff about the things people do and do not like, the support they need and how they communicate. In addition core care plans are in place for the things people need support with, particularly around their health and personal care needs. These plans contain some good information such as how the person showed if they were DS0000025237.V363541.R01.S.doc Version 5.2 Page 12 unhappy. Plans have been reviewed regularly which helps to ensure the information is as up to date as possible, should people needs change. However two plans we looked at contained assessment forms for the use of bed rails. One of these assessments had not been completed. As bed rails are not suited for everyone and could pose a risk for some people, whilst protecting others, it is important that these assessments are completed. We also found that care files contained a general lack of risk assessments for the person. These assessments should be used for everyday activities the person engages in or is supported with. If completed correctly they support the person to live a lifestyle of their choice whilst minimising any risk to them. Information about how people show their everyday choices and decisions is recorded in their care plan. For example one plan recorded how the person shows that they are not hungry or are not enjoying the meal provided. In discussion with staff they were able to explain how people non-verbally show their choices and decisions. Care plans record how and why some decisions are made in the person’s best interests, for example when spending large sums of money on their behalf. As the people living at Cherryvale do not use verbal forms of communication, this clear recording along with staff knowledge, helps to ensure that as far as possible, people are supported to make everyday choices and decisions for themselves. DS0000025237.V363541.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The people living at Cherryvale are supported well so they can live a lifestyle of their choice. EVIDENCE: During our visit we saw that the people living at Cherryvale were engaged in different activities. One person had gone out for the day whilst the other two people were spending time at home engaged in activities they enjoyed. We observed that staff took time to sit and chat with people as well as provide them with support when needed. Care plans contain information about the things people do and do not like to do when at home and out and about. In discussions with a member of staff she was able to explain the different places people like to go and how staff try to accommodate this. Daily records showed that people are supported to go out and about and spend their time at home engaged in different ways. For DS0000025237.V363541.R01.S.doc Version 5.2 Page 14 example, records for one person showed they had spent time in the garden, observed everyday household tasks, watched TV and listened to music. They had also been out shopping and on several outings. The people living at Cherryvale share the cost of a mini-bus which is adapted to meet their needs and helps them to get around more easily. A member of staff explained that none of the people living at Cherryvale have showed an interest in going to church. They have in the past supported one of the people living there to go, in order to establish if this was something they would like to do. The member of staff confirmed that if people wished to go to a local church then they would be supported to do so. Records and discussions with a member of staff confirmed that people’s visitors are welcomed at any reasonable time. In addition staff regularly support one of the people living there to go and visit their family. This support along with support to get out and about in the community enables people to maintain relationships and spend time with people other than staff. Records of menus in the home showed that people are offered varied diets. They also showed that staff take into account people’s preferences and will make different meals if required. A member of staff we spoke with was able to explain people’s preferences and how staff support people to ensure they get the nutrition and fluids they need to stay as healthy as possible. DS0000025237.V363541.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. People’s health and personal care needs and choices are generally identified and support provided to meet these. However they are not always supported to attend regular health checks in a timely manner, which could impact upon their health. EVIDENCE: People’s care plans contain clear information about the support they need with their personal and health care. In discussions with staff it was evident that they have a good knowledge of the people who live at Cherryvale and how to support them. For example a member of staff was able to explain how, through observation, they can understand that someone may not be feeling well, and the actions they would take. In meeting the people living at Cherryvale it was evident that they had received support from staff to meet their personal care needs. However records relating to regular health care checks for people indicated that these were not up to date. For example, one plan stated the person DS0000025237.V363541.R01.S.doc Version 5.2 Page 16 should see a chiropodist yearly and had last seen them thirteen months ago. It also stated they should see the optician yearly, but had not done so for over two years. As the people living at Cherryvale cannot verbally communicate, it is important that these annual checks are arranged them. If people are unable or unwilling to have these checks this should be clearly recorded, along with any alternatives checks that could be carried out. It would also help to note and deal with any potential health issues that may arise. A locked cabinet for the storage of medication is available in the kitchen of the home. We noted that one medication stated it should be stored below 22 degrees. No record of the temperature in the kitchen is maintained although it is likely temperatures will fluctuate in there. In order to ensure all medication is stored at the correct temperature to maintain its effectiveness, a record of the room temperature should be recorded at different times daily. Staff can then take action on this, if they find it is consistently too high. Care plans contain clear guidance about supporting people with their medication. This includes guidance on supporting them with medication they take ‘’as needed’ as well as information on the side effects of their medication and potential effects if missed. They also contain clear information and agreement from relevant parties about giving people their medication in their meal. The clear guidance to staff about how to support people with their medication helps to prevent errors occurring. The information recorded about giving people their medication openly in their meal helps to ensure that people’s rights are protected and that such decisions are taken in their best interests. Daily records of the receipt and dispensing of medication had been completed correctly. We checked a sample of medication against records and found that these tallied. An audit system for counting medication is in place, which helps to ensure medication is being given correctly and to quickly note and deal with any potential errors that could occur. In order to make this audit trail easier to follow staff should record the time they have counted the medication. At the time of our visit, only the date was being recorded, which can make it difficult to accurately count the medication that should be in the home on a later occasion. DS0000025237.V363541.R01.S.doc Version 5.2 Page 17 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 & 23 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Systems are in place at Cherryvale to ensure the people living there are safe from harm. EVIDENCE: No complaints or concerns have been raised about Cherryvale since our last big inspection there. There are policies in place from CIC to deal with any complaints or safeguarding adults issues that may arise. These clearly identify the actions and timescales that should be followed once a concern is raised. In discussions with a member of staff they displayed a clear understanding of safeguarding issues, how to notice indicators of this and the actions they should take. Information about how to raise a concern or complaint is made readily available to the people living at Cherryvale and their relatives via the homes brochure. At our last inspection we identified that the ways in which CIC supported people to manage their money were not clear and therefore it was not possible to establish if money was being managed in people’s best interests. At this inspection, clear records relating to how the organisation manage people’s money were in place. In addition a decision making financial plan had been put into place. This examines the various options open to people for transport and recorded why the decision to share a vehicle was in the person’s best interests. This clear planning, recording and evidence of best interest DS0000025237.V363541.R01.S.doc Version 5.2 Page 18 decisions, helps to ensure that people’s money is managed safely and well. We looked at samples of money held in the home along with records and receipts and found these to tally. DS0000025237.V363541.R01.S.doc Version 5.2 Page 19 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, 26, 29 & 30 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Cherryvale is maintained so that it provides a warm, comfortable home for people to live in that is adapted to meet their needs and choices. EVIDENCE: Cherryvale is a detached dormer bungalow located in a residential area of Woolton. It is near to local facilities and public transport, with some parking provided in the front driveway. At the back of the bungalow there is a large, well-maintained garden with seating areas, which are used by the people who live there. Everyone living at Cherryvale has their own downstairs bedroom, which is decorated and furnished to suit their needs and choices. There is a large lounge and dining room, which is comfortable, nicely decorated and provides sufficient space for people to move around comfortably. Since our last inspection of the home a smaller room has been turned into a second lounge. DS0000025237.V363541.R01.S.doc Version 5.2 Page 20 This gives people a more private space to meet with their visitors or spend time alone, if they wish. We identified at our last inspection that although the kitchen was domestic in appearance it was looking shabby. A member of staff advised us that the kitchen had been deep cleaned since and that a cleaning schedule is in place. However, maybe due to the age of the kitchen, it remains looking shabby, cupboards remain sticky to touch and cupboard lamination and sealant is starting to peel. If the kitchen is not replaced or repaired shortly it may begin to present a health and safety risk. The downstairs bathroom has been adapted with a shower that is fully accessible. In addition there are ramps to the front and back of the house, hoists and a shower chair and trolley available. These aids and adaptations help people to get around their home and receive support with their personal care, more easily. Upstairs there is a well organised laundry room that provides the equipment people need to ensure their clothes are well looked after and any risk of cross infection is minimised. Staff have access to disposable gloves and aprons that again help to minimise the risk of infection. However there is no supply of water soluble bags within the house. These bags can be used to deal with any potentially infected washing and a small supply would help to minimise a risk of infection spreading. DS0000025237.V363541.R01.S.doc Version 5.2 Page 21 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 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. The people living at Cherryvale are supported by a staff team who know them well. However a lack of up to date training for staff may mean people are not always supported as well as they should be. EVIDENCE: During our visit to Cherryvale we observed that staff took time to sit and communicate with people as well as meet their basic support needs. Staff displayed a good knowledge of the ways people living in the home communicate, the things they do and do not like to do and how to meet their support needs and choices. The majority of the staff team hold a national qualification in care (NVQ). However we identified at out last big inspection at Cherryvale that basic training for staff was out of date. At this inspection we were able to locate few training records for staff. For example, the self assessment form that had been sent back to us stated that staff have received training in medication and member of staff we spoke with told us they had had this training with the past DS0000025237.V363541.R01.S.doc Version 5.2 Page 22 twelve months. However staff records showed the last date staff had training in medication and the use of diazepam was in 2004. Records also showed that the last time staff had training in moving and handling people was in 2004. As the people living at Cherryvale require support in this area of their lives it is a matter of concern that staff are not receiving up to date training in this area. The records that were available showed that staff had undertaken training in fire safety and had up to date food hygiene certificates. CIC has a training department that offers training in both basic and more specialist areas of care. However no training plan for staff at Cherryvale had been put into place and it was not possible to establish what training they had undertaken within the past year or what was needed. This lack of training and forward planning of training for staff means that they may not be up to date with current good practice in how to support people safely and well. They may also not be up to date in the best ways of meeting people’s more specialist needs such as those related to their health. No new staff had started work at Cherryvale since our last inspection. However staff files showed that before anyone is employed to work at the home a series of checks is carried out on them. This includes obtaining written references and a Criminal Records Bureau check (CRB). These checks help to ensure staff are suitable to work with people who may be vulnerable. DS0000025237.V363541.R01.S.doc Version 5.2 Page 23 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 & 42 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. There are systems at Cherryvale to ensure the home is managed safely and well. However these are not always robust enough to ensure identified improvements are carried out in a timely manner. EVIDENCE: The manager at Cherryvale was appointed in November 2006. She is experienced in working with adults who have a learning disability. We identified at our last inspection in 2007 that she had not applied to register with ourselves as the manager of the home. At this inspection we had still not received an application from the manager to become registered as the manager of Cherryvale. This process helps to ensure that the manager is a fit and suitably qualified person to manage a service and is required by law. DS0000025237.V363541.R01.S.doc Version 5.2 Page 24 There are several systems in place to check the quality of the service provided by Cherryvale. These include a senior manager from the organisation visiting the home regularly and auditing the service. Following this a report is produced which identifies any areas for improvement and the timescales for meetings these. Although these identified that staff required training to keep them up to date, we found no evidence that this was planned. Yearly surveys are sent out by the organisation to seek the opinion of people who use the service, their relatives and others who support the person. These surveys provide people with a formal way to comment on the service provided and influence future changes. Records and certificates showed that the majority of heath and safety checks required are carried out in a timely manner. This includes checks on fire, gas and small electrical appliances. However the electric certificate needed to be renewed in September 2008 and this had not happened. Although the manager advised that she had contacted the housing association about this, not ensuring these checks are carried out in a timely manner could put people at risk. DS0000025237.V363541.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 3 2 3 3 X 4 3 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 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 2 X DS0000025237.V363541.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA35 Regulation 18(1)(c) Requirement A training plan must be compiled and implemented. This should cover all health and safety and basic training as well as more specialist training based upon peoples individual needs. This will help to ensure staff have the knowledge to support people safely. This requirement is outstanding from the last inspection. 2 YA9 13(4) Care plans must contain up to date risk assessments for all areas of the person’s life that may present a risk to them. This will help to ensure people can live a lifestyle of their choice whilst remaining as safe as possible. 3 YA42 13(4) A system must be put into place for ensuring all health and safety checks are carried out within the correct DS0000025237.V363541.R01.S.doc Timescale for action 31/08/09 31/08/09 31/08/09 Version 5.2 Page 27 timescales. 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 YA19 Good Practice Recommendations Annual health checks for people should be monitored to ensure they take place in a timely manner. This will help to ensure people are supported to remain as healthy as possible. The temperature of the kitchen should be recorded and monitored to ensure it is at the right temperature for the storage of medication. The time medication is audited should be recorded. This will help to ensure it can be accurately checked at a later date. Consideration should be given to replacing the kitchen units and worktops. This will help to modernise the room and ensure it does not become a health and safety risk. A small supply of water soluble bags should be available in the home. This will help to prevent or quickly deal with any outbreak of infection that may occur. 2 YA20 3 4 YA24 YA30 DS0000025237.V363541.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Regional Contact Team Unit 1, 3rd Floor Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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