Inspection on 02/07/07 for Church View

This inspection was carried out on 2nd July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 23 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Church View 19/01/09

Church View 15/01/08

Church View 05/07/06

Church View 12/12/05

Church View 21/06/05

Church View 30/11/04

Church View 01/06/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Church View Church Street Kimberworth Rotherham South Yorkshire S61 1EW Lead Inspector Sarah Powell Key Unannounced Inspection 2nd July 2007 09:40 DS0000003120.V337351.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 DS0000003120.V337351.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. DS0000003120.V337351.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church View Address Church Street Kimberworth Rotherham South Yorkshire S61 1EW 01709 557 658 01709 550 541 church.view@craegmoor.co.uk www.craegmoor.co.uk Parkcare Homes Limited 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) Post Vacant Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23) of places DS0000003120.V337351.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one named resident over the age of 65. Date of last inspection 5th July 2006 Brief Description of the Service: Church View is a care home registered to provide care for 23 residents with a diagnosis of mental illness. The home provides 24-hour care for people with enduring mental health needs. It encourages self sufficiency and self reliance where possible via a combination of staff support, and the teaching of independent living skills. The aim is to combine this with appropriate day care education and work experience, to encourage and foster social and community skills. Church View is organised into 3 separate houses, Vicarage, Canterbury, and York, all self contained, with single bedroom accommodation, bathroom/ toilet facilities, and separate kitchen, dining room and lounge facilities in all of them. The fees at Church View at the time of the inspection ranged from £314 to £903 per week, however this is different for each person at the home as it is calculated on the needs of each person. It is therefore necessary to contact the home for further information. Additional charges are made for daily newspapers and magazines. The registered person makes information about the service available via the Statement of Purpose, and the Service User Guide. DS0000003120.V337351.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection and took place over one day on 2nd July 2007 at 9:45am and finished at 16:30. As part of the inspection process the inspector spoke to 15 residents, 5 staff and a manager from another home who was overseeing Church View. During the inspection a tour of the building took place, observing the environment, staff and care practices. A number of records were examined these included medication, care plans, menus, staff rotas, recruitment, training and maintenance records. Feedback was given to the staff at the home and the area manager over the phone as there were serious issues identified during the inspection that required urgent attention. What the service does well: What has improved since the last inspection? What they could do better: Many areas have been identified in this report that require improvement to ensure service users needs are met. DS0000003120.V337351.R01.S.doc Version 5.2 Page 6 The environment was found in an extremely poor state bathrooms all require an upgrade, bedding needs replacing including quilts, quilt covers and pillows, carpets were encrusted in dirt and were very sticky. The kitchens were in a poor condition floor covering were not secured to the floor, grout between tiles was encrusted in grime. The seals behind the sinks were also encrusted in dirt and debris, all doors to room were sticky and dirty. The dining room furniture was dirty and the tablecloths were cheap plastic sheets that were not kept clean. A number of people living at the home told the inspector that they had been asking for their bedrooms to be decorated for ages. There was hardly any fresh food available in the home at the time of the visit and no fresh fruit or vegetables were available. The only food seen was frozen foods that did not give a varied healthy choice to the people in the home. The home had no maintenance person and the garden was not maintained, the grass needed cutting and the hedges and trees pruning. Many people at the home liked sitting outside but no garden furniture was provided. 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. DS0000003120.V337351.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 DS0000003120.V337351.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The assessments identified service users needs. EVIDENCE: A number of people who lived in the home were case tracked as part of the inspection process and full assessments were seen in their plan of care. The assessments clearly identified the needs of the service users and helped determine that the home could meet these needs. There had been one new admission since the last inspection this assessment had been carried out by the deputy and involved the individual. An assessment had also been carried out through care management arrangements, the service had received a summary of the assessment and a copy was in the plan. DS0000003120.V337351.R01.S.doc Version 5.2 Page 9 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. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care plans clearly identified needs, people made decisions and risk assessments were in place, however these were not always able to take place due to staffing problems. EVIDENCE: A number of care plans were seen and one person was case tracked, the plans contained good information about the people in the home, they identified the needs of the people who lived in the home and gave information on how these needs would be met. This included changing needs and aspirations of the person. The plans clearly identified procedures for people who were likely to be aggressive or cause harm, focusing on positive behaviour and ability, promoting safety of the people and staff in the home. DS0000003120.V337351.R01.S.doc Version 5.2 Page 10 The home operates a key worker system and the people were aware who their key workers were. They had good relationships with them one person said, “The staff are great they look after us very well”. Staff respected peoples choices to make decisions and supported them in these decisions. The people in the home were given choices but these had been limited due to the staffing problems in the home. The home was without a manager the deputy manager was on long term sick leave and there was only 9 care staff to cover all shifts. The activities co-ordinator was working on care to try to meet people’s needs and choices. All people who lived at the home had risk assessments for responsible risk taking whilst in the home, and also for leaving the premises. For holidays they were supported to take risks as part of an independent lifestyle. Support was limited due to the staffing in the home at the time of the visit. People in the home told the inspector that staff work very hard and tried to support them but they were very busy. Risk assessments were in place for smoking, and no body was allowed to smoke in their bedrooms, there was a notice warning of the dangers in every bedroom. In addition, staff have drawn up a smoking “contract” with people living at the home which states that all damage had to be paid for, and that people may be asked to leave the home if they are found to be smoking in their bedrooms or communal lounges. The home had provided a smoking room in the Canterbury unit, had installed an extractor fan to meet requirements of the new legislation, however the room opened directly onto the laundry room which was a communal area and the door was not kept shut, allowing smoke into the communal room. During the tour of the building it was also evident that some people were still smoking in their bedrooms, this places other people who lived at the home and staff at risk. DS0000003120.V337351.R01.S.doc Version 5.2 Page 11 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, 15, 16 & 17. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Activities were limited; people accessed the local community and maintained family relationships. The home did not offer a healthy diet. EVIDENCE: Activities outside the home continued and people attended various day centres and rehabilitation centres and the people that went out on their own continued to do so. However many people told the inspector there had not been many activities in the home during the day for a number of weeks. This was due to the activities co-ordinator working on care duties to cover the shifts. The home had a vehicle to use, which could carry up to seven people for outings, activities and appointments however there was only three staff who DS0000003120.V337351.R01.S.doc Version 5.2 Page 12 were willing to drive the vehicle, so this also restricted the activities for the people in the home. Four people had been on a holiday to Blackpool this year for five days and had a good time. Another holiday was booked for later in the year for a number of other people who wished to go on holiday. Staff told the inspector only one staff member went on holiday with the four people this could have put the people and the staff member at considerable risk. Links with family and friends were encouraged and maintained, people spoken to said they were able to have visitors at any time and were able to see their relative in private if they wished. Some people who lived in the home also went out to see their family and friends. The inspector observed the lunchtime meal, there was lack of healthy food choices and no fresh fruit or vegetables were available in the home, there was very limited stock of any fresh food. All food seen was frozen ready meals or tined food. The home does not have a designated cook the care staff have to prepare and cook all the meals. The people who lived at the home were able to make drinks when they wished each unit had a kitchen however all meals were cooked in the vicarage kitchen as this was next to the only dining room in the home. The people in the home did not help to prepare or cook the meals, they were able to help with this but staff did not have the time to encourage this, however they cleared up after the meal and washed the dishes. Meals were not nutritionally balanced or well presented and the dining room was dirty and not a congenial setting to eat a meal. The people in the home ate their meals very quickly and left the room, many refused to have any lunch. Records were kept of what people ate, but it was not clear if action was taken regarding this information. The care staff worked very hard and tried their hardest to meet the needs of the people in the home. There were three staff on duty on the day of the visit to 23 people, the inspector was told this was the usual staffing numbers, they had to do all the cooking and at weekends they were also expected to do the cleaning. This did not leave sufficient time to meet the needs of the people who lived in the home. DS0000003120.V337351.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People receive support in the way they prefer; their physical and emotional needs were partly met. Medication policies and procedures are in place but documentation needs to be improved. EVIDENCE: The home operates a key-worker system, and personal and emotional support is offered to residents from staff in the home as required. One person said to the inspector “staff support me very well”. Observations confirmed that staff do try to support people but they have little time for one to one support. Staff said that whilst the majority of people can rise or retire to suit themselves, some people require prompting to get up, otherwise some would stop in bed all day if allowed to. DS0000003120.V337351.R01.S.doc Version 5.2 Page 14 Staff said that people who lived in the home would generally inform staff if they were not well in the physical sense. Staff tried to recognise subtle changes in people’s behaviour which may be the early warning signs of something more serious approaching resulting from their mental ill - health. Any such concerns are recorded and monitored, and include the prompt referral to an appropriate specialist if considered necessary. All the people who lived at the home were registered with a GP Practice, and arrangements are in place for Chiropody Ophthalmic and Dental services in order that their needs are met. None of the people in the home were self–medicating, all medication is stored in one unit, all the people at the home will come to the unit to receive their medication. There is a medication profile for every person explaining the likely side effects of their medication, and all staff administering medication have now received accredited training. Two of the care staff have been promoted to team leaders and are responsible for ordering medication and ensuring all medication is in stock and accounted for. One person living at the home had medication altered during the monthly cycle so additional medication had been ordered. It was difficult to determine if this was given correctly as remaining medication from one month had not been transferred to the next months medication administration sheet. The occasional tablet was also unaccounted for, the staff told the inspector that sometimes the people in the home drop tablets or damage them so another has to be administered, yet this was not documented. The issues were discussed in detail with the team leaders who told the inspector they had received no specific training on how to order the medication but had in the short time they had been responsible made improvements to safeguard the people in the home. DS0000003120.V337351.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Peoples views are listened to but not always addressed, they protected from abuse. EVIDENCE: There have been a number of concerns raised by people in the home since the last inspection most had been satisfactorily dealt with. People spoken to during the visit raised issues regarding lack of pillows and wanting their bedroom’s redecorated and new carpets. They said, “I have been waiting ages” these issues have been taken up by staff in the home but are awaiting approval from higher management. The staff continue to address the issue of complaints at staff meetings to ensure that all staff are vigilant in recognising and recording when actual complaints are being made by people living at the home in order that their concerns can be dealt with. There is a policy and procedure on Adult Protection and, and there have been no Adult Protection incidents since the last inspection. DS0000003120.V337351.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 & 30. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The environmental standards were extremely poor and standards of cleanliness throughout were poor. DS0000003120.V337351.R01.S.doc Version 5.2 Page 17 EVIDENCE: A tour of the building took place during the inspection. Environmental standards were extremely poor and the home was not well maintained. Furniture and fittings for example chairs, tables, dining chairs, bedside cabinets, beds, wardrobes etc. were in a worn, torn and damaged condition. Floor coverings in bathrooms, toilets, bedrooms kitchens and dining room were badly stained and marked and many were not properly fixed to the concrete floor causing a tripping hazard. Many carpets in communal areas were so encrusted in dirt and debris that shoes to stuck to them. Wall tiles in bathrooms and toilets had come off the wall, grouting between tiles was encrusted in dirt and seals around baths, sinks and showers were damaged and soiled. Wallpaper in all bedrooms seen was peeling from the wall and not well maintained. The woodwork i.e. skirting, doorframes and windowsills were marked and paint was badly chipped. The doors into all room were very sticky and dirty. All curtains throughout the home were badly soiled and most were not fitted to the track properly. The bedding and pillows were in a poor state all looked like they needed washing or replacing and many pillows were lumpy and uncomfortable. One person told the inspector “I had four pillows but they keep going missing now I only have one”. The paper towel dispensers throughout the home were broken and no paper towels were available there was also no liquid soap in most dispensers which could lead to cross contamination. Three people who live at the home told the inspector they had been asking for their bedrooms to be redecorated and new carpets for months and still had no date as to when this was to be carried out. One bedroom seen had one wall that was so damp the plaster was falling off the wall. The person who lived in the room said, “its been like that for ages, they do know about it”. The dining room was located in the vicarage unit the tables and chairs were covered in food debris and the table clothes were cheap plastic covers that were also covered in food debris. And did not provide a congenial setting for the people to eat. The smoke room was located in one unit, however it opened onto the laundry room which was a communal space and the door did not have a self closure devise fitted. The laundry room was full of smoke. This obviously made all the laundry smell of smoke. DS0000003120.V337351.R01.S.doc Version 5.2 Page 18 The home had been without a maintenance person for a while and the gardens had not been tended for some time the grass was long and needed cutting. The hedges and trees needed cutting and pruning and the flowerbeds were full of weeds. People at the home told the inspector they liked sitting outside but had very few places they could do this with the state the garden was in. There was no garden furniture provided for the people in the home to use to enable them to sit outside. The overall condition of the environment was neglected and disrespectful to the people living and working at the home. This is one of the poorest standards the inspector has seen in a registered setting. DS0000003120.V337351.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Staff in the home are competent to do their jobs, recruitment procedures are robust staff are appropriately trained. There were not enough staff on duty to meet all the needs of the people in the home. EVIDENCE: Since the last inspection staffing levels have decreased yet the number of people in the home remains the same and the needs of these people had not decreased. There were three staff on each shift and 2 night staff. Due to the layout of the home and the needs of the people in the home this was not adequate. The Area Manager said there were 17 staff employed at the home however evidence seen by the inspector showed there were only 9 care staff employed to cover these shifts, staff spoken to also told the inspector that they were very short staffed. The manager has left and the deputy is on long-term sick leave. A manager from another home is overseeing things this arrangement is not satisfactory; it has a negative impact on the people in the home. DS0000003120.V337351.R01.S.doc Version 5.2 Page 20 With only 9 care staff this did not maintain the minimum numbers on each shift so they all had to work additional shifts to cover. The activities coordinator had worked as a carer for the last two weeks to cover the shifts and staff tried very hard to meet the basic needs of the people in the home. All the people spoken to all praised the staff and the commitment to the home. The staff training was very good all mandatory training had been carried out and the staff also received specific training on mental health to ensure they understood the needs of the people who lived at the home. Recruitment procedures were robust and protected the people in the home two staff files were looked at and they contained all the required information. While staff worked hard to care for the people living at the home, the overall result fell well below an acceptable level. This was due to insufficient numbers and lack of management support. DS0000003120.V337351.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home has no manager or deputy, quality assurance systems were in place. Health and safety procedures were in place although environmental health and safety was poor. EVIDENCE: The home has been without a registered manager for nearly a year, a manager was appointed during this period however was only in post a short while and left without giving notice. The deputy manager has been on long tem sick leave for a month and is not due back to work. This has had an impact in the quality of the service provided and has had a negative impact on the people who live in the home. DS0000003120.V337351.R01.S.doc Version 5.2 Page 22 The care staff worked very hard to maintain the home and provide the best care possible for the people in the home and many people told the inspector that the care staff are great and work very hard. A manager from another home was trying to oversee the home and was maintaining some of the quality assurance systems staff and resident meeting were taking place and their view are sought to ensure the home is run in their interests. The home has a good health and safety policy and all maintenance records were up to date these were being carried out by a maintenance person from another home when they were required, these included water temperatures, fire alarm testing and fire drills. The safety certificates for the gas, electric and portable appliances were up to date ensuring safety of the people in the home. The environmental checks were being carried out and the issues identified under the environment standards had been raised by the staff, quotes for work to be carried out had been submitted four times, but had not been approved. The provider visits carried out, had also identified the works required as far back as November 2006. This had been put as outstanding on every subsequent months report but still nothing had been done, causing a safety risk to the people who live in the home and the staff. DS0000003120.V337351.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 3 ENVIRONMENT Standard No Score 24 1 25 1 26 1 27 1 28 1 29 X 30 1 STAFFING Standard No Score 31 X 32 1 33 1 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 1 X 3 X X 1 X DS0000003120.V337351.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23 Requirement The registered person must ensure that the homes premises are suitable for its stated purpose. Accessible, safe and well maintained. (Old timescale 15/8/06) The staff must ensure the health safety and welfare of all people in the home with reference to smoking in their bedrooms, and other non-designated areas. (Old timescale 15/7/06) People in the home must be able to make decisions about their lives and assistance must be given. People living in the home must be able to take part in appropriate activities. The routines in the home must promote independence, choice and rights of the people living there. Healthy, nutritious, well balanced and attractively presented meals must be provided for people in the home. The documentation of medication DS0000003120.V337351.R01.S.doc Timescale for action 01/10/07 2. YA9 12 01/08/07 3. YA7 12 01/09/07 4. 5. YA12 YA16 16 12 01/08/07 01/08/07 6. YA17 16 01/08/07 7. YA20 13 01/08/07 Page 25 Version 5.2 8. 9. YA22 YA24 22 23 10. 11. YA25 YA26 16 16 12. 13. 14. YA26 YA26 YA26 16 16 16 15. YA27 23 16. YA28 23 must be improved, all medication must be recorded if not given and reasons why. The amount of tablets left at the end of the month must be transferred from one Medication administration sheet to the next. The views of people who live in the home must be listened to and acted on. Written confirmation must be provided giving details of when identified work is to start and what equipment, furniture and fittings have been ordered and dates they are due to be delivered to ensure the premises is suitable for its stated purpose. Written confirmation must also be provided when requirements have been complied with at the end of each timescale. The bedrooms in the home must be well maintained to suit people’s needs and lifestyles. The people living at the home must have good quality furniture and fitting provided in their bedrooms, new carpets and beds must be provided. The rooms must also be redecorated. New bedding must be provided for the people who live at the home. New pillows must be provided for the people who live at the home. New curtains must be provided in people’s bedrooms and communal areas to ensure they are properly fitted, clean and suitable for each room. Toilets and bathrooms must be upgraded and decorated to ensure they meet the needs of the people in the home. The shared space must be comfortable, accessible and wellmaintained new furniture, DS0000003120.V337351.R01.S.doc 01/10/07 24/07/07 01/11/07 01/11/07 01/08/07 01/08/07 01/08/07 01/11/07 01/11/07 Version 5.2 Page 26 17. YA28 23 18. 19. YA30 YA30 23 23 20. 21. YA32 YA33 18 18 22. YA37 8 23. YA42 12 carpets and curtains must be provided and rooms redecorated. The kitchens must also be upgraded and redecorated to ensure they are safe and well maintained. The gardens must be made accessible to people living in the home grass must be cut and hedges and trees pruned, garden furniture must be provided for the people to use. The premises must be kept clean, hygienic and free from offensive odours throughout. A thorough deep clean of the premises must be carried out to ensure the people who live there have a clean and hygienic home that is free from offensive odours. Competent and qualified staff must support people in the home at all times. Sufficient numbers of staff must be on duty at all time to meet the needs of the people who live at the home. A manager must be appointed who is qualified, competent and experienced to run the home and meet the needs of the people who live there. The works identified in this report must be carried out to ensure the health and safety of the people who live in the home. 01/09/07 24/07/07 24/07/07 01/08/07 01/08/07 01/08/07 01/11/07 DS0000003120.V337351.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000003120.V337351.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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