Inspection on 03/12/07 for Coachmans Drive (21)

This inspection was carried out on 3rd December 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 no outstanding requirements from the previous inspection report, but made 4 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) 17/01/07

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 Daniel Hamilton Unannounced Inspection 3 December 2007 09:30 Coachmans Drive (21) DS0000025240.V353818.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.V353818.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.V353818.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 Vacancy Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2007 Brief Description of the Service: 21 Coachmans Drive is an accessible three bed-roomed bungalow that is situated in the Croxteth Park area of Liverpool. At present there are only two people living in the home. The service is provided by Community Integrated Care and is registered to provide personal care and support to three adults with a learning disability. There is one acting manager and a team of six staff that support the people who live in the home. The property has 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. The home has a mini bus and there is also a local bus service within walking distance. The property is decorated and furnished to a good standard and provides a homely environment that is domestic in character. The Care Home Fees are £1,207.21 per week. Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted approximately 7 hours. Two people were being accommodated in the home at the time of the visit however only one service user was present during the inspection. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The Service Manager, Acting Manager and one support worker were spoken with during the visit. Likewise, the service user who was present during the inspection was encouraged to participate in the inspection process using their preferred method of communication. Survey forms were also distributed to family members/advocates of the people using the service, health care professionals and staff prior to the inspection, in order to obtain additional views and feedback about the service provided. All the key standards were assessed and progress/action taken in response to the previous requirements and recommendations from the last key inspection in January 2007 was reviewed. What the service does well: What has improved since the last inspection? Since the last visit, action had been taken to ensure risk assessments were reviewed, to ensure the welfare of the people using the service was safeguarded. Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 6 The Acting Manager had started to work towards the National Vocational Qualification – Registered Manager’s Award and was in the process of submitting an application to the Commission for Social Care Inspection to register as the manager of the home. Staff had received training in Fire Safety and arrangements had been made to ensure the fire alarm system was tested on a weekly basis. Furthermore, the fire safety officer had been consulted regarding the emergency lighting and door release mechanism and confirmed the devices were safe / satisfactory. What they could do better: An assessment of needs had not been completed before a new service user had moved into the home. The health, personal and social care needs of the people using the service must be assessed prior to admission to safeguard their welfare. Furthermore, care plans should be reviewed and updated to ensure they identify each person’s needs, the support required and personal goals. This will enable the service to further demonstrate that it is person centred and ensure staff have access to key information on the people they support. Some staff training records were incomplete and / or not up-to-date and highlighted that some staff had not completed all the necessary training for their roles. Action must be taken to ensure staff complete core and specialist training. This will help to provide evidence that the people using the service are supported by appropriately trained staff. At the time of the visit the service did not have a copy of an electrical wiring or gas safety certificate. Certificates must be obtained and available for inspection to confirm the services in the home are safe. The service should continue to further develop the Service User Guide to ensure the format is more suitable for the needs of people with learning disabilities. 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, so that the interests of the people using the service are safeguarded. The risk assessments for the use of bed rails should be further developed and reference should be made to guidance issued by the Medical Devices Agency to safeguard the health and safety of the people using the service. The service should consider the introduction of menu plans to avoid repetition. Furthermore, action should be taken to ensure accurate records are maintained of all meals provided. This will help the service to demonstrate that the people using the service receive a healthy diet. Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 7 Assessments of Competency should be undertaken for all staff responsible for the administration of medication. This will help the service to monitor the training needs and competency of staff. Furthermore, action should be taken to ensure the balance of medication stock is consistent with medication records and the use of medication labels on Medication Administration records should be discontinued to ensure best practice. Action should be taken to ensure all the necessary recruitment records are obtained and available for inspection in accordance with the Care Home Regulations 2002. 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. Coachmans Drive (21) DS0000025240.V353818.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 Coachmans Drive (21) DS0000025240.V353818.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 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An assessment of needs had not been completed before a new service user had moved into the home. Unless a full assessment of needs is undertaken prior to admission there is no assurance that the needs of people using the service will be met. EVIDENCE: Since the last visit the Acting Manager had produced a new Statement of Purpose and Service User Guide in a format more suitable for the needs of people with a learning disability. Advice was given on how the layout of the document and the use of pictures, signs and symbols could be further improved. The Acting Manager reported that one person had moved into the home since the last visit. The other service user had lived in the home for over seventeen years. Previous inspection records detailed that the organisation had procedures in place in relation to assessment and the Annual Quality Assurance Assessment detailed that policies were in place for referral and admission. The personal file of the new service user was viewed during the visit. Records did not contain a pre-admission assessment of need. An ‘Intake and Health Needs assessment was available on file however this had been completed several months before the person was admitted. Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 10 The Acting Manager reported that the service users had a tenancy agreement with Maritime Housing and a Contract with Community Integrated Care. At the last inspection it was noted that the tenancy agreements were available but the contracts were not. The personal files of both the service users were viewed during the visit. Only one file contained a copy of a ‘Support Agreement’ between the Provider and the service user. Consumer Hire Agreements were also in place for a shared motability vehicle. As previously recommended a relative or an advocate should be involved in the completion of any contract / agreement relating to the service users, to ensure this is the best interests of the service user. Coachmans Drive (21) DS0000025240.V353818.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning records are in need of review to ensure the needs of the people using the service are identified and planned for to promote independence, wellbeing and choice. EVIDENCE: The files of the two people living in the home were viewed during the visit. Each file contained a range of Care Planning documentation, a personal futures plan and / or an Essential Lifestyle Plan. Although the Acting Manager had updated a number of records since the last visit, some parts of the documentation were incomplete and goals / objectives had not been recorded. Examples were discussed with the Service and Acting Manager during the visit and advice was given on how the documentation could be further improved. The management team and the carer on duty demonstrated a good awareness of the needs, routines and preferences of the people living in the home despite the absence of some key information and the service users having little verbal communication. The person using the service who was present during the inspection appeared relaxed in the home environment and was seen to engage Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 12 in a positive way with the staff team by smiling, touching and / or making responsive sounds. The staff team continued to support the people living in the home to take responsible risks as part of their daily lives. The Acting Manager demonstrated a satisfactory understanding of the importance of assessing and managing risks and a range of risk assessments had been completed which had been kept under review. Advice was given to the Acting Manager on how to further develop the risk assessment for the use of bedside rails. Coachmans Drive (21) DS0000025240.V353818.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, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Meals, activities and routines were flexible and varied to enable service users to follow their preferred lifestyle. Menu planning and records are in need of review to demonstrate that the people using the service have a balanced and nutritious diet. EVIDENCE: The people living at 21 Coachman’s Drive did not attend any employment or educational facility. The Acting Manager reported that people using the service were encouraged to utilise community facilities and were supported to visit local facilities such as the local park, cinema, pubs, hairdressers and shops. Service users were also encouraged to participate in all aspects of their home life where possible. At the time of the visit, only one of the people living in the home was in contact with family. The Acting Manager reported that the service was in the process of trying to establish contact with the relatives of the other service user, to ensure the people using the service were supported to form Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 14 appropriate personal and family relationships. There were no restrictions around visitors coming to the house. Life in the home was based around what the people using the service want to do, unless there is a particular activity they need 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. The people using the service were assisted by staff to go shopping for household products, buy food and to prepare meals. A menu planning system had not been developed however a record of meals provided was in place. Some records viewed highlighted repetition and did not always detail the meals provided. Examples were discussed with the Service and Acting Manager. Systems were in place to ensure appropriate support was given by staff for people who required support with eating and drinking. Furthermore, the Acting Manager reported that specialist advice would be sought from the dietician and / or speech and language therapist when required. Coachmans Drive (21) DS0000025240.V353818.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of medication records is in need of review to confirm the healthcare needs of the people using the service are safeguarded. EVIDENCE: The people living at 21 Coachman’s Drive required assistance with all aspects of personal care and support. The Registered Provider (Community Integrated Care) had developed a range of care plan documentation for staff to record information on the support needs of the people using the service. Although some shortfalls in recording were noted, staff spoken with were able to demonstrate knowledge and understanding of the needs and support requirements of the people living in the home. Furthermore, staff were observed to interact with service users in a respectful and positive manner. Examination of health care records confirmed that the people using the service were supported to attend appointments with health practitioners including; doctors, dentists and chiropodists. No record of optician appointments could be found and this was discussed with the Acting Manager. The Annual Quality Assurance Assessment for the service detailed that staff Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 16 had access to a policy on the Control, Storage, Disposal, Recording and Administration of Medicines. Policies and procedures were available for reference on the day of the inspection. Medication was dispensed by a local pharmacist and administered by staff as the people using the service were unable to administer their own medication. The Acting Manager reported that staff completed an in-house medication course and received the opportunity to shadow experienced staff before being authorised to administer medication. At the time of the visit written assessments of competency had not been undertaken for staff responsible for handling medication. Medication was stored in individual medication cabinets that were fitted in each person’s bedroom. Medication Administration Records (MAR) were viewed during the visit and highlighted a number of issues. For example, the balance of Paracetamol did not correspond with written records and the prescribed instructions had not been recorded. Furthermore, labels had been removed from the supply boxes for some medication / creams and attached to the MAR. Advice was given on how to obtain a copy of guidance issued by the Royal Pharmaceutical Society of Great Britain for staff to reference to ensure best practice. Coachmans Drive (21) DS0000025240.V353818.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems had been developed to listen and respond to complaints and to safeguard and protect vulnerable people from abuse. EVIDENCE: The Registered Provider (Community Integrated Care) had developed a Complaints procedure however this did not include details of how to contact the Commission for Social Care Inspection. An accessible version was also available for reference. The Annual Quality Assurance Assessment for the service detailed that no complaints had been received since the last visit. Likewise, the Commission had received no complaints about the home. Records showed that the Registered Provider had developed an adult protection procedure and a whistle-blowing policy. A copy of the Liverpool City Council Inter Agency Adult Protection Procedures was available in the home for staff to reference. Records showed that the majority of staff had completed training in the Protection of Vulnerable Adults and staff spoken with demonstrated an awareness of how to recognise and respond to suspicion or evidence of abuse. Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is pleasant and generally well maintained. This provides the people using the service with a safe, clean and comfortable environment. EVIDENCE: 21, Coachman’s Drive is a bungalow situated in a residential area. 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. The accommodation included a spacious lounge and dining area (which provided suitable access for people who use a wheelchair) and two bedrooms, a domestic style kitchen, bathroom and a staff office. On the day of this visit the home was clean and appeared safe. There were spacious gardens to the rear of the building that were well maintained. ‘Annual Scheme Monitoring visits’ were undertaken by Maritime Housing Association (the Landlord) to monitor the condition of the building. Likewise, Community Integrated Care (The Registered Provider) had established systems to ensure the home was kept clean and in good order. Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 19 The premises was comfortably furnished and provided a domestic and homely environment for the service users. At the time of the visit the kitchen units were in need of modernisation and the paint in the laundry room was in need of attention as it was peeling off. Records showed that both the issues had been reported to and noted by Maritime Housing Association. The Acting Manager reported that the boiler and central heating system was due to be replaced shortly. The Annual Quality Assurance Assessment for the service detailed that policies and procedures had been developed for Communicable diseases and infection control. Previous inspection records detailed that the Registered Provider provided suitable personal protective equipment such as gloves and aprons and arrangements for clinical waste to be disposed of were in place. The Acting Manager reported that a representative from Merseyside Fire and Rescue Service visited the home during February 2007 who confirmed the fire safety systems in the home were satisfactory. Advice was given on how to further improve record keeping in this area. Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff recruitment and training records are in need of review to fully safeguard the welfare of the people using the service. EVIDENCE: 21 Coachman’s Drive had a team of four permanent support workers and two regular bank staff as noted at the last visit. Two staff were on duty each day from 7.30 am to 8.00 pm and one waking night staff was on duty from 7.30 pm until 8.00 am. The Acting Manager reported that the home had vacancies for three staff however the posts had not been recruited to as the existing staff had picked up extra shifts as and when required. The Acting Manager confirmed that the staffing levels and number of hours worked by staff were being closely monitored to ensure the people using the service had access to sufficient numbers of staff and continuity of care at all times. The Annual Quality Assurance Assessment for the service detailed that the Registered Provider (Community Integrated Care) had a policy on recruitment and employment including redundancy. Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 21 Four staff had commenced employment at the home since the last visit. One of the employee’s files could not be checked, as it had not been transferred from another region. One of the three files checked did not contain an application form and another file only contained one reference. Each file contained confirmation that a Criminal Record Bureau check had been completed. Examination of the Annual Quality Assurance Assessment for the service and discussion with the Acting Manager confirmed that one member of staff had completed a National Vocational Qualification in Care at level 2 or above and that two staff were working towards the award. No certificates were available for inspection at the time of the visit. Once all three staff have completed the award and received their certificates, (49.99 ) will be qualified to NVQ level 2 or equivalent. Community Integrated Care had a training department, which delivered certain core training. The organisation had also developed a ‘CIC academy e-learning system’ which covered induction training; core skills part 1, 2 and 3; Safety at Work; Food Hygiene; Person Centred Learning; First Aid; Moving and Handling and Communicating Effectively. Practical training was also provided for Moving and Handling, First Aid and Basic Food Hygiene. Staff files viewed did not contain a record of training completed however documentary evidence of training undertaken was available on files viewed. Some gaps were evident as noted at the last visit. Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of some maintenance records is in need of review to confirm the health and safety of the people using the service is fully safeguarded. EVIDENCE: At the time of the visit the home did not have a manager who was registered with the Commission for Social Care Inspection. The Registered Provider (Community Integrated Care) had appointed Julie Connolly as the Acting Manager. Ms Connolly confirmed that she was in the process of submitting an application to the Commission for Social Care Inspection to register as the Manager. The Acting Manager reported that she had completed a range of training that was relevant to her role and was in the process of working towards the level 4 National Vocational Qualification (NVQ) – Registered Manager’s Award. Advice Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 23 was given regarding the need to also complete a level 4 NVQ in Health and / or Social Care and to develop an up-to-date training record. The Service Manager continued to undertake Regulation 26 visits to the home. This involved carrying out an audit of all aspects of the service users health and welfare, the environment, complaints and staffing levels. Quality audits were also completed on a six-monthly basis and previous inspection records detailed that a financial audit was carried out once a year by the organisation. Team meetings were coordinated on a regular basis and minutes maintained. Systems were also in place for an annual survey to be sent out from head office to service users and / or their relatives asking for their views of the home and service provided (where practicable). Information received via the Annual Quality Assurance Assessment (dataset) for the service confirmed policies and procedures had been developed on Health and Safety. Likewise, the dataset confirmed that equipment in the home had been serviced and / or tested periodically however the dates of the last electrical circuit and gas appliance test had not been recorded. Fire records were viewed for the property which confirmed the alarm system had been tested on a weekly basis and that the fire extinguishers and emergency lights had been visually / manually checked each month. An up-todate fire risk assessment was also in place. At the time of the visit the home did not have an electrical wiring certificate in place (as noted at the last inspection) and the last landlord’s gas safety certificate was dated 30/05/06. The acting manager reported that the gas safety check was due to be completed during December 2007. Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 3 X X 2 X Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA2 Regulation 14 Requirement A full assessment of need must be completed before people move into the home to ensure the needs of prospective service users are identified. Each member of staff must have an up-to-date record of training completed including induction training to provide evidence that the people using the service are supported by an appropriately trained team. All staff must receive training in core and specialist subjects and the training must be updated at appropriate intervals to provide evidence that the people using the service are supported by an effective team. An electrical wiring and gas safety certificate must be obtained and available for inspection to confirm the wiring and gas supply is safe. Timescale for action 03/02/08 2 YA35 17 (2) Schedule 4 03/02/08 3 YA35 17 (2) Schedule 4 03/03/08 4 YA42 23 03/02/08 Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 26 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 YA5 Good Practice Recommendations The service should continue to further develop the Service User Guide to ensure the format is more suitable for the needs of people with learning disabilities. 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 so that the interests of the people using the service are safeguarded. Care plans should be reviewed and updated to ensure they identify each person’s needs, the support required and goals. This will enable the service to further demonstrate that it is person centred and ensure staff have access to key information. The risk assessments for the use of bed rails should be further developed and reference should be made to guidance issued by the Medical Devices Agency to safeguard health and safety of the people using the service. The service should consider the introduction of menu plans to avoid repetition. Furthermore, action should be taken to ensure accurate records are maintained of all meals provided. This will help the service to demonstrate that the people using the service receive a healthy diet. The service should ensure that the people using the service are supported to attend optician appointments and records of the outcome of appointments should be maintained to demonstrate that all the health needs of service users are met. Action should be taken to ensure the balance of medication stock is consistent with medication records and the use of medication labels on Medication Administration records should be discontinued to ensure best practice. Assessments of Competency should be undertaken on all staff responsible for the administration of medication. This will help the service to monitor the training needs and competency of staff and to ensure best practice. The contact details of the Commission for Social Care Inspection should be included in the Organisation’s Complaints procedure so that people are aware of how to DS0000025240.V353818.R01.S.doc Version 5.2 Page 27 3 YA6 4 YA9 5 YA17 6 YA19 7 YA20 8 YA20 9 YA22 Coachmans Drive (21) 10 11 YA32 YA34 contact the Commission. 50 of the staff team should hold a National Vocational Qualification at level 2 or equivalent to ensure compliance with National Training Targets. Action should be taken to ensure all the necessary recruitment records are obtained and available for inspection in accordance with the Care Home Regulations 2002. Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG 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. Extracts may not be used or reproduced without the express permission of CSCI Coachmans Drive (21) DS0000025240.V353818.R01.S.doc Version 5.2 Page 29 - 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. 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