Inspection on 17/01/07 for Coachmans Drive (21)

This inspection was carried out on 17th January 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coachmans Drive (21) 02/09/08

Coachmans Drive (21) 03/12/07

Coachmans Drive (21) 07/11/05

Coachmans Drive (21) 06/06/05

Coachmans Drive (21) 16/12/04

Coachmans Drive (21) 04/10/04

Similar services:

Clover House

Parkside

Park Lodge

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Park House

Extracts from inspection reports are licensed from CQC, this page was updated on 18/02/2010.

CARE HOME ADULTS 18-65 Coachmans Drive (21) 21 Coachmans Drive Croxteth Park Liverpool Merseyside L12 0NX Lead Inspector Lesley Owen Key Unannounced Inspection 17th January 2007 11:00 Coachmans Drive (21) DS0000025240.V309217.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 Coachmans Drive (21) DS0000025240.V309217.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. Coachmans Drive (21) DS0000025240.V309217.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coachmans Drive (21) Address 21 Coachmans Drive Croxteth Park Liverpool Merseyside L12 0NX 0151 220 9729 9999 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) www.c-i-c.co.uk. Community Integrated Care Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Coachmans Drive (21) DS0000025240.V309217.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: 21 Coachmans Drive is registered to provide care for three adults with a learning disability, at present there are only two service users living at the home. Service users have single bedrooms, there is a large lounge that contains a dining area, a bathroom with bathing aids, kitchen and an office. There is a private, enclosed garden to the rear of the home and an open plan front garden and driveway. There is wheelchair access to the property. The home is situated in a quiet residential area in Croxteth Park. The home has a mini bus, there is also a local bus service within walking distance. There are shops, parks, pubs and restaurants in the area. Coachmans Drive (21) DS0000025240.V309217.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced site visit began at 11am on the 17th January 2007 and took place over six hours. Throughout the inspection the newly appointed manager and a support worker on duty at the time were present. The inspector was also able to speak to the Service manager for the service who was at the home at the start of the visit. During the inspection time was also spent examining records held for the service user living at the home, staff records, a sample of maintenance records were also seen and a tour of the house was made. In addition the manager had completed a pre-inspection questionnaire which provided the inspector with additional information. What the service does well: What has improved since the last inspection? What they could do better: To continue to develop care plans for service user/s and that dates and information is recorded when risk assessments are reviewed. To make information available for service user/s in formats suitable for the resident group. To ensure that where a service user doesn’t have a family Coachmans Drive (21) DS0000025240.V309217.R01.S.doc Version 5.2 Page 6 member or representative to act on their behalf the services of an advocate are obtained. To develop a comprehensive activities programme including activities outside the home that is based around the needs and interests of service user/s. To ensure that all staff receive training in core subjects at the appropriate intervals and specialist training provided to ensure that staff have the necessary skills and knowledge to support service users. A programme to provide staff with NVQ should be implemented and a training plan drawn up to ensure that the training targets for this standard are met. To submit an application to register the manager of the service and to provide the manager with the required training to equip them with the knowledge to full fill the role. 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. Coachmans Drive (21) DS0000025240.V309217.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 Coachmans Drive (21) DS0000025240.V309217.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): 1, 2, 3, and 5 The quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. Information should be made available in formats that assist prospective service users to make a decision about moving into the home. New service users would be fully assessed prior to moving into the home to ensure their needs would be met. In order to support and protect service users the services of an advocate should be provided where the person has no one to advocate on their behalf. EVIDENCE: The home has a service user guide which contains all the required information. However as at the time of the last inspection the guide needs to be made available in different formats suitable for the resident group the home is registered to provide a service for. It is acknowledged that the current service user may not benefit from this but this must be considered for prospective service users. Until recently two service users lived at Coachmans Drive and had been resident in the home for over fifteen years. Sadly one resident passed away recently at the home. As no service users have been admitted to the home for a number of years assessment procedures have changed significantly. The organisation have clearly identified procedures in relation to the assessment process and comprehensive guidelines as to who should be involved which would be used if a new service user were to be assessed in the future. Records held indicated that prospective residents would have a full assessment and all parties involved in their care would be consulted and involved in this process Coachmans Drive (21) DS0000025240.V309217.R01.S.doc Version 5.2 Page 9 where possible. From discussions with the managers prospective service users would be able to visit the home to meet the current service user and viceversa. The manager is aware that the due to the complexity and individual needs of the service user currently living at the home and taking in to account that they have lived there for such a great length of time, the assessment process and matching of any new service user admitted to the home is crucial. The home is currently staffed by four permanent staff members and as there are three staff vacancies bank staff provides additional cover in order to ensure staffing levels are maintained. Within the staff group information provided in the pre-inspection questionnaire indicates that no staff have obtained a National Vocational Qualification (NVQ) to date. However the inspector was informed that two staff are to undertake this qualification and the manager approved to undertake NVQ4. (Training will be discussed in more detail later in this report.) At the last inspection it was reported that the service users have a tenancy agreement with Maritime Housing and a contract with Community Integrated Care. The tenancy agreements were available but the contracts were not. In the previous inspection issues were raised in relation to who completes the contract for a service user where the service user or family member are unable to do so. It was therefore recommended that an advocate be approached regarding the completion of contracts where this an issue, this remains the same. At the time of the last inspection a Consumer Hire Agreement was available and indicated that the service user agreed to pay a weekly cost towards the cost of the mini bus. This was signed by representatives of CIC. As previously recommended a relative or an advocate should be involved in the completion of any agreement relating to the service users contributing to the cost of the home’s minibus, to ensure this is the best interests of the service user. The current charges at Coachmans Drive are based on the individual care package of the service user and they pay rent of £61.25 to the housing association that owns the property. Additional charges are made for hairdressing, leisure activities, other personal items and £41.05 is payable for transport. Coachmans Drive (21) DS0000025240.V309217.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 The quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Care plans were in place to ensure the individual needs of the service user were met and risk assessments were in place to support work with the service user. EVIDENCE: The care plans and essential lifestyle plan for the service user living at Coachmans Drive was examined. Since the last inspection the information available had been reviewed and amended but still required development. The plans included information in relation to morning and evening routines, partly completed medical profile, personal support required, diet and communication. Further written information around the service users communication needs, social history and activities is needed and other information should be reviewed and amended where required. The manager confirmed that it is her intention to develop the information available and work had already been started. It was clear from the information available and observation on the day that the service users likes and dislikes and preferences around daily living were respected. A record of daily events is also completed by staff and it is recommended that a record of checks made during the night should also be maintained. Coachmans Drive (21) DS0000025240.V309217.R01.S.doc Version 5.2 Page 11 Risk assessments are carried out for both personal and environmental risks and action taken to minimise identified risks and strategies are put into place to assist the service user. It was noted at the time of this visit that the gas fire is currently unguarded a risk assessment should be carried out and action taken to minimise any identified risk. As at the time of the last inspection it remained unclear whether risk assessments were up to date as they were not dated. The manager explained that the risk assessment form is to be changed and will include on the back a record of when assessments are reviewed. It is recommended that all the risk assessments are reviewed as a number were no longer required and others needed to be brought up to date. The manager confirmed that it was her intention to do this and had already requested that the current manual handling assessment be reviewed by the organisations occupational therapist. Where bed rails are used risk assessment must be completed regularly reviewed. Both the manager and support worker on duty at the time of this visit demonstrated that they had a good knowledge of the individual service users needs and how these are communicated despite the service user having little verbal communication. Good relationships were observed to have been developed between staff and service users throughout the time of this visit. Coachmans Drive (21) DS0000025240.V309217.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): 11.12, 13, 14, 15, 16 and 17 The quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. The staff should continue to develop the activities available to the service user to ensure that they are offered opportunities to take part in appropriate leisure and social activities in the local community. Meal times are provided in a relaxed and unhurried manner. EVIDENCE: The service user living at the home does not currently undertake any employment or attend any educational facility. However they are supported to go out into the community as much as possible and visit the local hairdressers, go out for meals, accompany staff to the shops and visits are made to a nearby sensory room. The service user is also encouraged to participate in all aspects of their home life where possible, but opportunities are limited. At the time of the last inspection concern was raised that staffing levels were at times restricting the opportunities for service users to go out. As the home is currently staffed by two support staff at all times and only one resident is at the home this was not an issue at this visit and provides staff with the opportunity to explore and develop activities the service user likes to do. Coachmans Drive (21) DS0000025240.V309217.R01.S.doc Version 5.2 Page 13 However as the home still has three staff vacancies this is an issue that needs to be addressed when a new service user is admitted. From discussion with the manager it was confirmed that staff support service users to maintain family links, and family are actively encouraged to visit the home. There are no restrictions around visitors coming to the house. Life in the home is based around what the service user want to do, unless there is a particular activity they have to attend. Service users can get up when they wish, spend time in the lounge or in the privacy of their own room as seen on the day of inspection. Currently all meals are prepared by staff and the service user accompanies staff when they go shopping for household products and to buy food. Where a service user requires assistance to eat the appropriate support is given by staff. Records are kept and specialist advice would be sought from a dietician when required. Menu planning in the home had lapsed and is to be reintroduced and an up to date record of all food provided maintained. Coachmans Drive (21) DS0000025240.V309217.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 The quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Care plans give clear guidance to staff to assist the service user in the way that meets individual needs. Medication procedures are in place and arrangements are in place to ensure that service user receive and have access to all healthcare services. EVIDENCE: The service user living at the home at the time of this visit requires assistance with personal care and how this should be provided is laid out in their care plans. All personal care is provided in service user’s bedrooms or in the bathroom and staff respect their privacy as much as possible whilst maintaining their safety. The file inspected included specialist assessments undertaken and as referred to previously a new manual handling assessment had been requested. Appropriate technical equipment and assistance is provided which is regularly serviced. Records show that the service user is supported to attend healthcare appointments. Arrangements are in place for service users to access the services of an optician, dentist, chiropodist or other health care professionals as required. When medication is prescribed it is dispensed by staff, as the service user is unable to administer their own. All staff are allowed to administer medication Coachmans Drive (21) DS0000025240.V309217.R01.S.doc Version 5.2 Page 15 after they undertaken in-house training. When medication is prescribed where possible it is administered from a Monitored Dosage System and recorded on the corresponding Medicating Administration Record sheets. Medication is stored in individual medication cabinets that are fitted in the individual service users bedroom. Coachmans Drive (21) DS0000025240.V309217.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 The quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. The complaints procedure should be made available in formats that reflect the needs of the service user group. Staff require training in the protection of vulnerable adults in order to protect and promote the rights of service users. EVIDENCE: The home has a detailed complaints procedure with timescales for action and responses to concerns raised. Consideration should be given to making the procedure available in a format more suitable to the needs of the service user living at the home and the needs of prospective residents. No complaints have been made to the Commission for Social Care about the home since the last inspection or received by the home. The organisation has an adult protection procedure and a copy of the Liverpool City Council Inter Agency Adult Protection Procedures. A whistle-blowing policy is also available. From discussion with the manager and examination of staff files, although the manager is aware of what to do if a concern were to be raised, staff have received no formal training this must be addressed quickly. Coachmans Drive (21) DS0000025240.V309217.R01.S.doc Version 5.2 Page 17 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, 25, 26, 27, 28, 29 and 30 The quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. The home is domestic in character and provides service users with a safe, homely and well maintained environment EVIDENCE: The home is a bungalow situated in a residential area of the city. It is in keeping with other properties in the area and there are no outward signs that it is a care home. It is currently registered to provide accommodation for 3 service users but the smallest bedroom has been converted to an office. It is therefore recommended that an application be submitted by the organisation to vary the registration. Accommodation includes a spacious lounge and dining area, which provides suitable access for those who use a wheelchair. Two bedrooms, a domestic style kitchen, bathroom and a staff office. On the day of this visit the home was warm, clean and airy. There are spacious gardens to the rear of the building that are regularly maintained. The home is comfortably furnished and provided a domestic and homely environment. Since the last inspection the bathroom/shower room has been Coachmans Drive (21) DS0000025240.V309217.R01.S.doc Version 5.2 Page 18 completely refurbished to a high standard. Appropriate aids to assist with bathing were provided. Laundry facilities are situated in a utility area that has been created at the back of the garage. It is recommended that additional storage space be provided in this area so that incontinence products can be stored. Infection control policies are in place and the company provides suitable personal protective equipment such as gloves and aprons and arrangements for clinical waste to be disposed of were in place. The garage at the time of this visit was full of furniture and other items that should be removed and disposed of or stored correctly. In the previous inspection reports a recommendation was made that consideration should be given to moving the fuse box inside the house to ensure that service users and staff are safe. At present staff have to go outside to the garage if the electricity fails to operate the trip switch. Coachmans Drive (21) DS0000025240.V309217.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 The quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. Training should continue to be promoted in the home to ensure that staff have the appropriate skills and knowledge to meet the needs of service users. EVIDENCE: Since the last inspection the whole staff group in the home has changed. After an internal investigation last year when concerns were raised about the management of the service the then manager was relocated and the remaining staff subsequently moved within the service of left. As a result an acting manager (who is now the appointed manager for the service) moved to the home and staff have been recruited or transferred to the service. The home at the time of the inspection was being staffed by four permanent members of staff and bank staff until the remaining three vacant posts are filled. No agency staff are being employed to staff the home and it is the managers intention to reduce the usage of bank staff as vacancies are filled. It is understood that recruitment is on going to the vacant posts. During discussions the manager demonstrated an awareness of the need to monitor that staff working extra hours does not have a negative effect on their ability to undertake their duties effectively. It is her intention when fully staffed and the home fully occupied to ensure that there is flexibility within the rota to enable staff to be able to undertake outside activities with service users as recommended at the last inspection. Coachmans Drive (21) DS0000025240.V309217.R01.S.doc Version 5.2 Page 20 As required at the last inspection records relating to staff recruitment as required have been transferred to the home. The staff files for two members of staff were examined and contained with minor omissions evidence that all required documentation had been obtained in relation to employment. It is recommended that staff files are reorganised to ensure easy access to information and certificates for all courses completed are obtained. Community Integrated Care has its own training department which delivers certain core training and also uses E- Learning which all staff can access via lap top computer available in the home. Training records available confirmed that a programme to up date core training for staff had been implemented, but not fully completed, this must be addressed and certificates made available on file. Within the new staff group no staff have achieved a National Vocational Qualification, but two staff have been nominated and accepted to begin this training. Induction and foundation is provided for new staff and the inspector was able to see documentation competed as part of the induction process and speak to a member of staff about the training provided for her to date as part of her induction. Coachmans Drive (21) DS0000025240.V309217.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 The quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. The home is well maintained to ensure the safety of service users and staff. EVIDENCE: The current manager was appointed in December 2006; prior to this she had been the acting manager of this service for a number of months. Before moving to Coachman’s Drive she had worked for the organisation for six years and held the position of senior support worker within the supported accommodation service also provided by the organisation. The manager has undertaken training in medication handling, sign language2/3/4, Essential Lifestyle Planning, dealing with epilepsy, administration of Midozolan and Rectal valium as well as the core training required. At present she is up dating all core training. The manager informed the inspector that she previously began NVQ2 but this was not completed. The manager is aware that she will need to undertake additional training in a number of areas e.g. providing supervision in order to fulfil the role of manager. An application to register the manager must be submitted to CSCI and the procedure to be followed discussed with the manager. Coachmans Drive (21) DS0000025240.V309217.R01.S.doc Version 5.2 Page 22 The Service Manger carries out the Regulation 26 visits to the home which involves carrying out an audit of all aspects of the service users health and welfare, accidents, risk assessments and staffing levels. It is understood that a financial audit is carried out once a year by the organisation and an annual survey is sent out from head office to the relatives of service users asking for their views of the home and service provided. A random sample of records held in the home were checked, these included, fridge and freezer temperatures, gas safety certificate, PAT testing and fire safety. The manager must ensure that the fire alarm is tested weekly and recorded as there were omissions in records held and that all staff receive fire training at the appropriate intervals and records maintained as confirmation that this training was up to date was not available. It was noted that there had been problems with the emergency lighting and the visiting engineer had recommended additional lighting be installed. In addition the door release mechanism to the new back door had not been reconnected, it is recommended that advice be sought from the Local Fire Safety officer and advice acted upon. The pre-inspection questionnaire also confirmed that other checks in relation to maintaining a safe environment had been undertaken and certificates were available with the exception of an electrical wiring certificate. During the visit the manager was able to confirm that this check had been undertaken and the housing association who owned the property would have the certificate and she would ensure that a copy was obtained for the home’s records. Coachmans Drive (21) DS0000025240.V309217.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 3 2 3 3 2 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 3 X X 2 x Coachmans Drive (21) DS0000025240.V309217.R01.S.doc Version 5.2 Page 24 Yes 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 YA9 Regulation 13 Requirement The registered person must ensure that risk assessments are regularly reviewed and should include a risk assessment for the use of bed rails and a risk assessment in relation to the gas fire. The registered person must ensure that staff receive training in core and specialist subjects including the protection of vulnerable adults and that the training is up dated at the appropriate intervals. A training plan for completion of the above should be forwarded to CSCI. The registered person must ensure that the manager is provided with the required training. The registered persons must ensure an application form is forwarded to CSCI with regard to the registering of a manager within the stated timescale. The registered person shall after consultation with the fire authority make suitable arrangements for: DS0000025240.V309217.R01.S.doc Timescale for action 17/01/07 2 YA35 18 17/03/07 3 YA37 9 28/02/07 4. YA37 8 17/03/07 5 YA42 23 28/02/07 Coachmans Drive (21) Version 5.2 Page 25 1.staff to receive training in fire prevention at the appropriate intervals and ensure that dates are recorded. 2 ensure that the weekly alarm tests are recorded as there were a number of omissions. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA1 YA3 Good Practice Recommendations The service user guide could be made more suitable to the needs of prospective service users. Further written information around how service users communicate their needs should be made available for staff to ensure that they and future staff can as far as possible communicate effectively with each service user. An independent advocate should be involved in the completion of any agreement for a service user who does not have family members or a representative to act on their behalf. To continue to develop care planning in the home. The service users and their representatives could benefit from the homes complaints procedure being more user friendly. It is recommended that consideration be given to moving the fuse box inside the house to ensure that both the service users and staff are safe during the night. To remove all unwanted items from the garage and to create additional storage space in the utility area at the rear of the garage. To consult with the local fire safety officer with regard to the provision of emergency lighting and the door release for the back door. 3. YA5 4 5. YA6 YA22 6 7 8 YA24 YA24 YA24 Coachmans Drive (21) DS0000025240.V309217.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Coachmans Drive (21) DS0000025240.V309217.R01.S.doc Version 5.2 Page 27 - 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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