Inspection on 03/10/07 for Coalway House

This inspection was carried out on 3rd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coalway House 03/03/09

Coalway House 09/04/08

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Coalway House Coalway House 54-56 Coalway Road Penn Wolverhampton West Midlands WV3 7LZ Lead Inspector Debra Lewis Unannounced Inspection 3rd October 2007 10.45 Coalway House DS0000068648.V352323.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 Coalway House DS0000068648.V352323.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. Coalway House DS0000068648.V352323.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coalway House Address 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) Coalway House 54-56 Coalway Road Penn Wolverhampton West Midlands WV3 7LZ 01902 341204 Swan Village Care Services Limited (None in post) Care Home 9 Category(ies) of Learning disability (9), Mental disorder, registration, with number excluding learning disability or dementia (9) of places Coalway House DS0000068648.V352323.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide personal care (excluding nursing) and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: Learning Disability (LD) 9 Mental Disorder (MD) 9 The maximum number of service users to be accommodated is 9. 2. Date of last inspection None – service registered in April 2007 Brief Description of the Service: Coalway House is a care home providing personal care for up to 9 adults, male or female, with a learning disability and/or a mental disorder. The home has 9 single bedrooms that are on the ground and first floors. All bedrooms meet minimum space requirements and offer en-suite toilet and hand basin facilities. Four rooms also provide en suite shower facilities. There are also communal W.C & separate bathroom and shower room on each floor, communal lounges on each floor and a ground floor kitchen and dining room. There is also a small laundry room and a large rear garden with a patio area. The home has its own transport provided and is well served by a regular public transport system. It is close to local shops and facilities, and is about a mile from Wolverhampton City Centre. The registered provider of the home is Swan Village Care Services Limited, a wholly owned subsidiary of Minster Pathways Limited. The nominated responsible individual is Mr Colin Farebrother. At the time of registration in April 2007 there was a manager in post who was registered to manage the home. However, he left the home before anyone moved in and the home has since had two acting managers. Coalway House DS0000068648.V352323.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection since it was registered in April 2007. It was a Key Inspection. This means that the inspector checked all of the standards which have most impact on service users. This report includes findings from the visit to the home, as well as any relevant information that has been received about the home since the last inspection. This includes details from a report on the home provided by the acting manager. The inspector was in the home from 10.45 a.m. until early evening. The inspector met and talked with 3 of the 5 service users; with several staff on duty; and with the acting manager. Surveys were distributed to the people living in the home but responses had not been received at the time of writing this report. What the service does well: What has improved since the last inspection? What they could do better: The home badly needs a settled, full time manager, as it has had 3 managers so far in 6 months. This means a lot of essential work has not been done and no one has been properly in charge. The home needs to keep detailed records of exactly what help is needed by each person who lives in the home, and of what the staff need to do to keep people safe. Coalway House DS0000068648.V352323.R01.S.doc Version 5.2 Page 6 The home needs to improve how staff keep and give out medicines, to make sure people living in the home are safe and healthy. The home must make sure all staff know who to tell and what to do, if they ever thought someone was being badly treated. The home needs a safe, warm smoking area. Staff need more training to make sure they give good quality care to people living in the home. The home must do proper checks on all staff before they start work, to make it less likely that people living in the home aren’t looked after properly. The home needs to do regular checks of the service given to people living in the home, to see what needs to be improved. Staff need training in fire safety, to reduce the risk of fire to people living in the home. 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. Coalway House DS0000068648.V352323.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 Coalway House DS0000068648.V352323.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): 1, 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Written information about the home was available. The home obtains enough information about people who may move into the home to be sure they are able to provide the care needed by each person. EVIDENCE: At the time of registration, an appropriately detailed statement of purpose and service user guide was made available. The copy of the statement of purpose provided during the inspection was inaccurate as it stated that the home provided residential accommodation for adults with a past alcohol or drug dependency. The home is not registered to provide a service to people with this as their primary need so this reference should be removed from the statement of purpose. The home had so far admitted 6 people, all as emergency (and possibly temporary) admissions so usual procedures had not been followed. However the files checked included all relevant assessments from social services departments. The home had carried out further detailed assessments of people’s exact needs in everyday circumstances. These were to be used to draw up service user plans. Coalway House DS0000068648.V352323.R01.S.doc Version 5.2 Page 9 3-month reviews were due to be held for each person who lived in the home, involving their social worker, CPN (community psychiatric nurse) and advocate if appropriate. The reviews were to establish how their first 3 months in the home had gone, and to discuss whether they wanted to stay in the home or move elsewhere. Coalway House DS0000068648.V352323.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home is working to establish people’s needs and wishes, but these are not recorded so consistency of care is not guaranteed. People using the service are not as safe as they should be because staff do not yet keep records of what they do to reduce risks to people living in the home. Privacy is not assured because personal records are not kept securely. EVIDENCE: Service user plans and risk assessments were in place for only one of the five people living in the home. The acting manager was working on the rest. This meant that there was no clear record of what support was needed by each person living in the home, or of how and when this was to be given. Staff relied on what they knew or what other staff told them. This practice leads to a risk of inappropriate care, especially where there is a high proportion of new or relief staff in the home. The plan which was in place was detailed enough to show exactly how the person preferred to be supported. However, there was Coalway House DS0000068648.V352323.R01.S.doc Version 5.2 Page 11 no evidence of the person’s involvement with the plan or of the frequency of support needed e.g. how often support was needed with washing. People living in the home said they were able to ask staff to help with what they wanted to do, and did not report any restrictions on their choices. At the moment people living in the home were very pleased about being able to choose what kinds of meals were provided in the home. Staff were working with them to gently encourage them to feel able to make further choices, for example about activities they might want to do. There were no risk assessments for individual people living in the home, except for one person. Again this was work being undertaken by the acting manager. This meant the home did not have a clear record of what risks they were aware of in relation to each person who lived in the home, and what action they undertook to reduce these risks while allowing as free a lifestyle as possible. Personal details about people living in the home could not be guaranteed to be kept confidential, as there was no lock on the office door, where records were kept. Coalway House DS0000068648.V352323.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home are gradually getting to know the area and staff are helping them do activities of their choice when they feel ready. Staff also support people living in the home to have contact with families and friends. People living in the home feel staff treat them with respect, and they say the food is very good. EVIDENCE: The 5 people living in the home had only been there for 3 months and their placements were not yet permanent. Therefore arrangements for regular activities had been limited. Also, as they had moved in under difficult circumstances due to the sudden closure of their previous home, staff had been working hard on getting to know them, and helping them to feel settled and secure in the home, and had only recently begun to investigate further activities for people living in the home. Coalway House DS0000068648.V352323.R01.S.doc Version 5.2 Page 13 Nonetheless there was evidence of activity and improvement in people’s daily lives. One person was out visiting a relative (accompanied by staff). One said he could go out more now than in his previous home, and had been visiting a local club with a friend. Another said she could go out with staff when she wanted, for example she had been shopping for clothes recently – she said this didn’t happen much where she used to live. There were weekly residents’ meetings, where people living in the home could discuss things like what food they wanted, activities, holidays, and the staffing situation. Relatives had visited the home and people living in the home were accompanied (if necessary) to visit relatives. There was a separate lounge where visitors could meet. As people living in the home were new to the home and the area, staff had concentrated on settling them in and had not yet considered issues such as people living in the home holding their own keys. The inspector saw a meal being served, which was freshly cooked and looked appetising. Several people living in the home said how fresh and good the food was, one person said they had kippers and orange juice (as requested) for breakfast most days. Bowls of fruit were available and staff reported that people living in the home ate large quantities of this. Coalway House DS0000068648.V352323.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People living in the home are satisfied with their care but it is not recorded properly, meaning it may not be given consistently as needed. People cannot be certain that their medications will be managed appropriately as storage is not as secure as it should be and not all staff have been trained. EVIDENCE: People living in the home had no complaints about care, but personal and healthcare support needs were only recorded for one person who lived in the home. This was not satisfactory as it meant there was no record of what care needed to be given, meaning staff relied on what they remembered and what another staff member said. This was a particular concern with new people living in the home who had arrived with few details of their care needs, together with new and temporary staff. The acting manager said she was intending to complete these plans this week. It was disappointing that they had not been prepared when people first moved into the home – they could easily have been revised as staff got to know people better. Coalway House DS0000068648.V352323.R01.S.doc Version 5.2 Page 15 Health assessments were not completed. The home had been disadvantaged by receiving no records from the previous home, so they did not know when routine health checks had last taken place. However records of current health appointments, e.g. fortnightly depot injections, were not being kept. It would be difficult to track down what healthcare had been provided, should any problem occur. All people living in the home were registered temporarily with the local GP practice and were still under the care of their existing consultant psychiatrist. No staff had training in working with people with mental health support needs. The inspector saw medication storage, administration and records. Storage was insufficient and the home needs to obtain further medication cabinets to ensure all medication is always stored safely. Medication records were mostly properly kept. The inspector advised that staff need to ensure they are consistent about which codes are used – the letter A was used when medication was not given, but its meaning was not defined. There were no written protocols for “as required” medication. The acting manager said guidance was needed from the consultant, however in the meantime “as required” medication was still being used (albeit infrequently) so a protocol must be in place. For one person there was a record they had taken “as required” sedative “for aggressive behaviour” but there was no entry in the daily notes that described such behaviour (although a blank space had been left on that day). All such occurrences must be fully documented for the safety and well being of people living in the home. Not all staff who handled medication had done training in safe administration of medication, although they worked in pairs. Coalway House DS0000068648.V352323.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People living in the home are able to tell staff about their concerns, but the home is not well prepared to act properly if there should be concerns about possible abuse of people living in the home. EVIDENCE: The home had a suitable policy for handling complaints. There was not yet a record of any concerns or complaints. The inspector advised it is good practice to record any concerns, no matter how minor, in order to monitor trends and to ensure all concerns are taken seriously and are acted on. People living in the home felt they could talk to staff. The home’s adult protection policy was misleading as it stated “All reports of abuse…should immediately be investigated and acted upon by the person in charge.” This is unsafe practice and is inconsistent with local multi-agency procedures. Any possible abuse should NOT be investigated by home staff unless this has been agreed under these procedures following a referral to the local authority and, if appropriate, the police. In addition, only one staff member had done training in “Abuse awareness”. This means there is a risk of unsafe practices being followed and of possible abuse not being reported or properly investigated. The acting manager and the deputy were due to do this training before the end of 2007. Coalway House DS0000068648.V352323.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. 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 home is clean and well kept. People living in the home have their own rooms with en-suite facilities, which they like. At the moment there is no provision for people who smoke. EVIDENCE: There are 9 single occupancy bedrooms on the ground and first floors. All bedrooms meet minimum space requirements and have en-suite toilet and hand basin facilities. Four rooms (two on each floor) also have en suite shower facilities. Facilities are in accordance with relevant sections of the National Minimum Standards for younger adults. These include bedroom fittings, communal W.C & separate bathroom and shower room on each floor, thermostatic water controls, ground floor dining room and kitchen, communal lounges on each floor, a small laundry room and a staff/emergency call system throughout most of the premises, A staff area/office is provided on the first floor. Storage space is available in the home and a separate storage cupboard is provided for substances Coalway House DS0000068648.V352323.R01.S.doc Version 5.2 Page 18 hazardous to health. There is a large garden and patio area at the back of the house, and a small parking area at the front. People living in the home were pleased with their rooms, including the ensuite facilities. The home still needed to be made more homely, as it was adequately but sparsely furnished and decorated. The acting manager explained that, as and when people living in the home became permanent residents, then the home could be better furnished according to their tastes. The home lacked a suitable smoking area. Smoking was not allowed in the house so people living in the home smoked on the patio, which had worked during summer months. However during the inspection it began to rain. One person chose to sit outside in the rain to smoke, while another stood in the doorway, meaning smoke was entering the house. The acting manager said a pre-fabricated shelter was going to be erected. The inspector advised this needed to happen very soon before the cold weather, and that they must ensure it is safe, warm and suitable for people living in the home. Upstairs windows had been fitted with restrictors, but on looking round an unlocked empty bedroom, the inspector came across one which was wide open, posing a risk of serious injury from a fall. The restrictor had been unhooked to allow it to open wide. This was brought to the attention of the acting manager who agreed to immediately check all other windows and if necessary arrange for more suitable restrictors to be put in. The home was clean and appeared to be well maintained on the day of the inspection. Coalway House DS0000068648.V352323.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): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People living in the home like the staff, but the staff team is not settled and people living in the home notice this. Staff do not have enough training to give the care people need. The home is not careful enough about ensuring staff do not work in the home until they have been properly checked, meaning people living in the home are at risk of having unsuitable staff working with them. EVIDENCE: The staff team was not fully established. There was an acting manager working part-time in the home and part-time in a neighbouring home run by the same company, Beaconhurst. There was a new deputy manager who had moved from Beaconhurst. There were 5 other care staff, 2 of whom were very newly recruited. Other staff from Beaconhurst and from an associated Domiciliary Care Agency worked shifts in the home as required. This produced a lack of continuity of staff, which had been noted by people living in the home during a house meeting. The acting manager said they were still recruiting but she was hoping the team would soon become settled. Of the deputy and other 5 care staff, only 2 held a NVQ (national vocational qualification) at level 2 or above. 2 others were undertaking this at level 2 or 3. Coalway House DS0000068648.V352323.R01.S.doc Version 5.2 Page 20 People living in the home said they liked the staff in the home and the inspector observed friendly and respectful interactions. Staffing levels were on the low side, with normally 2 care staff on duty through the day, plus the manager for 20 hours a week (although her actual hours were not shown on the rota). This did not encourage staff to initiate outings with people living in the home. Staff recruitment records were patchy. Three staff records sampled showed two were employed on only a POVAfirst check, before their full CRB disclosure had arrived. There was no evidence of the home following the procedures required in these circumstances, such as ensuring that a suitable staff member had been appointed to supervise them and be on duty at the same time as them. In fact one such new staff member had worked 6 shifts between August 12th and September 2nd, with no designated senior staff member on duty. 5 shifts had been with staff who were not regular employees in the home. This poses a significant risk to people living in the home of being exposed to poor practice or harm. Staff training was sparse, with no staff having had training in mental health. Of the 7 regular staff members (manager, deputy and 5 other care staff) 4 had not had food hygiene training, although care staff prepared all food. 3 did not have health and safety, manual handling or infection control training. Training records for the home were not easily available, as they included staff from another home. Coalway House DS0000068648.V352323.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 is suffering from lack of stable management and has no registered manager. This is affecting many aspects of the service provided to people living in the home. There is not an established way of monitoring the quality of the service provided. People living in the home are not as safe as they should be because health and safety is not consistently managed and fire safety training is urgently needed. EVIDENCE: The home was registered in April 2007, but the manager who was part of this registration left the home soon afterwards, before anyone moved in. The home then had an acting manager, and only since August has the current acting manager been in place (3rd manager in 6 months). (She is registered manager Coalway House DS0000068648.V352323.R01.S.doc Version 5.2 Page 22 of another home, Beaconhurst, and currently works 20 hours a week in each service.) This is a regrettable situation which needs to be urgently addressed, as the home needs a permanent, full time and appropriately trained registered manager. The acting manager is well liked by staff and people living in the home and is said to be “very person-centred”, focusing on individual needs. However her time in this home has been very limited so there is a large amount of management work outstanding (see whole report). There is no established system of quality assurance leading to annual development, although the acting manager said the home will use surveys, CSCI reports, regulation 26 reports and AQAA [professional reports provided to CSCI] contents to plan improvements. Some aspects of health and safety management in the home were acceptable, but there were significant gaps – including a lack of risk assessments covering general working practices and individual people living in the home, and no fire safety training for staff. Coalway House DS0000068648.V352323.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 2 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 2 23 1 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 1 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 1 X 1 X 1 X X 1 X Coalway House DS0000068648.V352323.R01.S.doc Version 5.2 Page 24 N/a 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 YA6 Regulation 15(1)&(2) Requirement Up to date, fully detailed service user plans must be in place for each person who lives in the home. This is to ensure that all staff know exactly what care is needed by each person. Up to date, fully detailed risk assessments must be in place for each person who lives in the home. This is to ensure that people living in the home can undertake activities as free as possible from avoidable risks. Full records must be kept of the healthcare needs of, and treatment given to, each person who lives in the home. This is to ensure staff know what healthcare people living in the home need, and when it was given. Medication must be managed according to recognised safe practice. This must include safe storage and staff training. This is to ensure the health and safety of people living in the home. There must be an appropriate DS0000068648.V352323.R01.S.doc Timescale for action 31/10/07 2 YA9 13(4)(b) 31/10/07 3 YA19 17(1) 31/10/07 4 YA20 13(2) 31/10/07 5 YA23 13(6) 30/11/07 Page 25 Coalway House Version 5.2 6 YA28 7 YA32 8 YA34 9 YA35 10 YA37 11 YA42 12 YA42 policy on Safeguarding Adults and staff must receive suitable training in this subject. This is to reduce the risk of abuse to people living in the home. 23(2)(a) A safe and suitable smoking area must be provided, to ensure the safety and welfare of people living in the home. 18(1)(c) A minimum of 50 of care staff must hold an NVQ level 2 or above in care, to ensure people living in the home are supported by suitably qualified staff. 19(1)&(5) Safe recruitment procedures must be completed for every person employed at the home. This is to ensure that people living in the home are less at risk from unsuitable staff. 18(1)(c) All staff in the home must receive the training they need for their work. This includes (but is not limited to) mental health, food hygiene, safeguarding adults, and safe handling of medication. This is to ensure that the people living in the home receive a consistent good quality of care. 8(1)&(2) The registered provider must appoint a permanent, full time suitable manager and inform the Commission accordingly. This is to ensure the home is properly managed. 13(4)(a)&(c) All risks to people living in the home must be assessed and recorded, and appropriate action taken to reduce these risks. 18(1)(c) All staff must have sufficient and regular fire training. This is to reduce risks to people living in the home from fire. 30/11/07 31/03/08 19/10/07 30/11/07 30/11/07 10/11/07 30/11/07 Coalway House DS0000068648.V352323.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 3 4 Refer to Standard YA1 YA10 YA16 YA22 Good Practice Recommendations The registered provider should ensure the accuracy of the statement of purpose. The office door lock should be fitted as soon as possible to reduce the risk of inadvertent loss of confidentiality. Consideration should be given to provision of keys to people living in the home. There should be a record of all concerns raised by people living in the home, together with action taken as a result. Coalway House DS0000068648.V352323.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Coalway House DS0000068648.V352323.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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