Inspection on 25/06/07 for Column Care Ltd

This inspection was carried out on 25th June 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Column Care Ltd 27/06/06

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Alfred House Residential Care Home

Barkerhouse Road (123)

Fernhaven

Thames House

Creative Support

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

CARE HOME ADULTS 18-65 Column Care Ltd 40 Carlin Gate Blackpool Lancashire FY2 9QT Lead Inspector Mrs Ruth Edgington Unannounced Inspection 25th June 2007 11:00 Column Care Ltd DS0000066398.V338018.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 Column Care Ltd DS0000066398.V338018.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. Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Column Care Ltd Address 40 Carlin Gate Blackpool Lancashire FY2 9QT 01253 596369 01253 596387 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) Column Care Limited Mrs Kathleen Veronica Gorton Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home is registered for a maximum of 7 service users in the category of MD (mental disorder, excluding learning disability or dementia). Bedroom numbers 1 and 7 may only accommodate clients who are in short term placements of six months or less. Any clients accommodated in room number 7 must be given exclusive use of the adjacent wc and provided with a key for this. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 27th June 2006 Date of last inspection Brief Description of the Service: The home is an adapted property registered to accommodate younger adults of both sexes who have a mental health disorder with the aim of rehabilitating clients in order that they can become as self sufficient as possible and live independently in the community. The home is situated in close proximity to the promenade, local shops and public transport routes. There are seven bedrooms, all of which are single and six have an en-suite facility. The seventh bedroom has a toilet adjacent to it, which is for exclusive use of the person accommodated in this bedroom. There are a number of lounge areas including a smoking a room, and a large dining room as well as a therapy room. Information received on the day of the visit showed that the fees for care at the home were based on the individual clients assessment and ranged from £950.0 per week to £1400.0 per week. Additional charges are made for hairdressing, toiletries, conti-pads and holidays. A copy of the Statement of Purpose/ Service User Guide is available for anyone making enquiries about the home. The written information explains the care service that is offered and what the residents can expect if they decide to live at the home. Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was undertaken as part of the home’s key Inspection visit. The visit commenced at 11.00am and took place over three and a quarter hours. Prior to the visit the manager completed a pre-inspection questionnaire, which provided information about the people living in the home, staff and other information, which assisted in assessing how the home was meeting the National Minimum Standards. Comment cards were sent out prior to the visit to enable people to have their say about the service provided, however only two were returned and these had been completed by care professionals who had contact with the home. At the time of the inspection the home was accommodating five clients, two of whom were not present at the time. As part of the visit the records of three clients were looked at in detail, staff records and a sample of other relevant records were also looked at. Conversation with the clients was very limited due to their willingness to communicate. Discussions took place with the manager, the chef, deputy manager and general conversation took place with the staff on duty. A tour of the home was also undertaken. From the observations made, comments received and the written documentation examined, the information has been put together to produce this report. What the service does well: The manager and her staff are working very hard to provide a quality service and whilst there areas for improvement were identified during the visit the overall findings were that the needs of the clients presently accommodated were being met. Comments received from care professionals that have used the service were in the main very positive. One said that they would have no hesitation in recommending the home to any of their colleagues. Another commented that, “The home is family run with a warm, caring family atmosphere. The manager and staff work closely with other professionals, such as care Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 6 co-ordinators, doctors, consultants and education facilities, to meet the individual needs of the residents. Staff are “enablers” rather than “carers”, they work with the individual clients to encourage them to become more independent by assisting them to develop social and independent living skills in order that they can move on to their own accommodation. Examination of the care plans and observations made during the visit confirmed that equality and diversity is promoted and the clients are treated with respect and dignity. What has improved since the last inspection? What they could do better: It was noted that there were still requirements and recommendations outstanding from previous inspections and the manager was reminded that these should have been dealt with in the timescale that had been set. The manager stated that she was aware that there was a need for improvements in some areas and would ensure that these would be worked through in order that the clients receive a consistent and reliable service that is of a high standard. Written information provided to prospective clients should include information about the staff in order that the clients can be assured that they will receive care from staff who are experienced, qualified and in sufficient numbers to meet their needs. Documentation should be reviewed to ensure that it is clear for people to follow, understand and be correctly completed by the staff. Confirmation in writing that the home can meet their assessed needs should be given to the clients before admission. Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 7 The receipt and disposal of all medication coming into the home should be clearly recorded to provide a clear audit of medication being taken by the residents to ensure that there is no mishandling and that the residents are protected by the procedures in place. Shortfalls in the recruitment of staff could potentially put clients at risk and therefore these procedures must be improved. Staff development should include a formal induction process and mandatory training including food hygiene, moving and handling, first aid and health and safety. The manager stated that specific training for staff in relation to mental health was being looked into, however staff should also continue with their NVQ (National Vocational Qualification) training to ensure that clients receive care from a qualified and competent work force. The manager should continue to work towards obtaining the relevant management qualification in order that the home is managed by a qualified, experienced and competent person. Whilst evidence was found that the manager and staff work closely with other professionals, comments were received prior to the visit that indicated that in one instance when asked for clarification about a specific issue the individual had not received an answer. In order to maintain an open and transparent service the manager was advised to ensure that good communication between all stakeholders continued. Effective quality assurance and monitoring systems should be developed to ensure that the views of people with access to the service are sought in order to measure the success in achieving the aims and objectives of the home and the goals for the clients. 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. Column Care Ltd DS0000066398.V338018.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 Column Care Ltd DS0000066398.V338018.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 good. This judgement has been made using available evidence including a visit to this service. A full assessment prior to admission is carried out to ensure that the clients’ needs are met. EVIDENCE: The records of three of the people using the service (referred to by the home as clients) were looked at and were found to contain very detailed information. Evidence was found that an assessment of needs had been undertaken before each individual was admitted to the home. Information included the general health care needs, mental wellbeing, medication, cultural, spiritual, emotional, sexual needs and a skills assessment including communication skills. Comments were received from two health care professional before the visit, confirming that the assessment arrangements ensured that accurate information had been gathered in order that the needs of the individual’s were met. The manager was reminded that before any client was admitted to the home confirmation in writing that the home can meet their assessed needs should be sent to them. Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 10 The admission pack given to all prospective clients, whilst containing information about the care and service to be provided, had been noted previously that the information in relation to the number of staff and their relevant experiences was not included. The manager confirmed that the documentation was in the process of being reviewed in order that clients were provided with all the information that they would require in order that they can make an informed decision about moving into the home. Examination of the individual records found that one client had not yet signed a contract, however confirmation was given by the manager that this was being dealt with and she explained the reasons for the delay. The documentation provided to clients in relation to the terms and conditions of residence was found to be very detailed and could possibly be difficult to understand and therefore consideration should be given to reviewing the way in which it is written in order that clients are clear about what they can expect. Comments received prior to the visit indicated that clients were made aware of what they could expect of the service. Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 &9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning systems ensure that changing needs and personal goals are reviewed regularly with the clients. EVIDENCE: Following the initial assessment the staff work closely with the clients to develop a “Life Plan Package”, which addresses the long term needs of the individual with a view to rehabilitation into the community. This is done over a period of time and the individual goals are prioritised to ensure that staff can assist the clients to achieve these. Information received confirmed that one client had an overnight stay to get to know the home and their personal preferences had been built into their care plan at every stage. The information identifies what the individual client’s capabilities are and what they require assistance with. Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 12 Risk assessments are carried out as part of encouraging independence. Evidence was found to confirm that care plans are reviewed and any changes made to ensure that their needs continue to be met by the service provided. Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 &17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities for development and community participation are addressed in the care plans, ensuring that people have a life style that meets their individual needs and expectations. EVIDENCE: Examination of client records confirmed that they are enabled to undertake activities that are appropriate and have the opportunities for personal development. One client was working on a voluntary basis at a local charity shop and this had proven to be very beneficial in their personal development. Clients have a weekly planner for activities, which includes any counselling or therapies that they wish to take part in such as reflexology or in the case of female clients, beauty therapy, which has been found to increase their self – esteem. Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 14 Two of the clients attend the local college. A computer has been made available in the home and one client in particular found this helpful in resuming some college work. Tutors have been brought in to assist the client to begin to develop confidence to be able to access the local college. Clients also enjoy going out for lunch and arrangements are made for those who wish to access the gym and swimming facilities in a local hotel. Comments received prior to the visit indicated that the interests of one client had been responded to by the staff in a detailed, individual and caring manner. The client’s behaviour had been handled sensitively and skilfully and the client was very aware of the acceptable boundaries of living with other people. There are no restrictions regarding client contact with family and friends, although visits to the home are infrequent. Information in relation to contact with family and friends is recorded on each individuals file. One client refused to have any contact with their family and this was respected. On the day of the visit one of the clients was due to return from a stay with their family. The clients are encouraged to be involved in the shopping and preparation of meals were appropriate. Information received prior to the inspection indicated that the clients had a choice of menus and that their dietary needs and preferences were catered for. The manager and chef confirmed that they were in the process of developing new menus and that the choice of meals was very much dictated by individual preferences. None of the clients had special dietary needs at the time. One client spoken to said that the food was good and that everything was ok. Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 &20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that clients’ mental well-being is continually assessed and reviewed so that their needs are met. EVIDENCE: The files of three clients were looked at in detail and were found to contain information in relation to their general health and areas requiring assistance from staff. Evidence was seen of contact with health professionals and actions taken to comply with their advise. Information received prior to the visit from care professionals indicated that they felt that the health care needs of the individual that they had contact with were properly monitored and attended to by the staff. One stated that the individual was stable and very pleased to be at the home. Evidence was seen that the day-to-day support is recorded and that the regular reviews are taking place. It was noted that in some cases certain records were not being completed, such as the record of weight. This was brought to the attention of the manager, who was advised that if a record was Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 16 felt to be appropriate then it should be completed and if not then this should be indicated in the documentation. It was again pointed out that the volume of information contained in each file should be reviewed to ensure that staff complete appropriate documentation fully to ensure that the needs of the clients continue to be met. Information received from the manager prior to the visit indicated that the procedures for the management of medication had been reviewed. On the day of the visit it was noted that the services of a different chemist was being used and that this was the first day. The member of staff responsible for medication was in the process of setting up new record sheets for the each individual client. All staff who administer the medication had previously received training , however the member of staff stated that due to the change of chemist and the monitored dosage system to be used, training had been arranged to take place that week for all staff in order that they are aware of good practice. All medication was kept in a secure locked metal cabinet in a locked room. A record was kept of all the medication, what it was for and any possible side affects. A record was also kept of any medication not taken and the reasons why. To ensure that the staff have a clear audit of all medication coming into the home, being administered and any returned, the manager agreed to review the records to ensure that the information is recorded in a style that is detailed but easy to follow for the protection of the clients. Comments received from care professional indicated that they felt that the service managed the medication of individuals correctly. Some concerns were raised in the comments received in relation to the therapy sessions that are carried out in the home. The manager confirmed that she only undertook therapies in which she was qualified and for other therapies offered, the services of a qualified person were acquired. The manager also said that these services were only provided if appropriate and the individual wanted to participate. Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s policies and procedures make sure that clients are supported and protected. EVIDENCE: There is a complaints procedure in place and it is included in the information given to prospective clients. There has been one complaint made to the Commission for Social care Inspection (CSCI) since the previous inspection and this resulted in a random inspection being undertaken to the home to look into any possible breaches of the Regulatory Regulations and National Minimum Standards. As a result a number of requirements and recommendation were made. An open approach to encourage comments through client meetings and daily discussions goes some way in ensuring that concerns are addressed prior to them becoming formal complaints. Observations were made during the visit of the positive interaction between the staff and the clients and whilst the clients were not very responsive to any questions asked of them, there was no areas of concerns raised. The home has a policy in relation to the protection of vulnerable adults and includes a missing persons procedure that has been developed with the local police. Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 18 The manager stated that training was being provided to staff by the local authority in Safeguarding Adults and also staff received some training in relation to identifying abuse as part of their NVQ (National Vocational Qualification) training. Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The clients live in a comfortable homely and safe environment. EVIDENCE: A tour of the home was undertaken and it was found to be warm, clean and free from any obvious hazards to the safety of the clients accommodated. The home has a variety of communal spaces, which encourages independence and freedom to associate with persons of their choice or have somewhere to go to be quiet other than their bedroom. There have been no changes made to the building since the last inspection, however the manager stated that it is their intention to make changes to one bedroom in order to provide en-suite facilities in that room. The manager was reminded of the need to inform the appropriate agencies to ensure that any changes comply with individual legislation. The home has a passenger lift, however this had been out of commission since the owners took over the Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 20 home and was unlikely to be put back into use due to the cost and the fact that the clients did not require this facility. A comment received prior to the visit indicated that one client in particular did not like staff entering their room and this was being respected, however there was a need for some shelving units to be provided. When spoken to during the visit, the client clearly indicated that they did not wish such storage to be provided. The manager stated that they were working through this situation. Information received through the documentation completed by the manager prior to the visit confirmed that the services and equipment in the home had been checked and that the home was well maintained to ensure that the clients are accommodated in a comfortable and safe environment. Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls in the recruitment and induction procedures could potentially put clients at risk. EVIDENCE: From examination of the records of three staff members it was clear that the recruitment procedures had not been followed correctly and therefore the clients could potentially have been placed at risk. All potential staff complete an application form however in one instance this had not been dated. In the case of two of the staff members there had been only one reference received although in one case there was evidence that a further reference was being chased up. Clearances had been received through the Criminal Records Bureau(CRB), this included a check under POVA First( Protection of Vulnerable Adults. Evidence that staff had undertaken a formal induction programme was very limited there was only reference to this on one of the files examined . Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 22 Evidence was seen that two of the six staff have gained level 2 NVQ and that all staff were undertaking NVQ training at level 3, as this was felt to be more appropriate to the client group and also training was being looked into specific for caring for people with mental health problems. One of the staff member’s file looked at showed that they had experience of working in a caring environment and that they had received training whilst in that post. This included equality and diversity, abuse and nutrition. There was little evidence of any mandatory training being undertaken. The manager stated that obtaining the correct recruitment documentation and training had been the responsibility of the unit manager who had recently left and therefore the manager had taken over these duties and was working through all the records to ensure that any shortfalls were rectified. Staff spoken to said that they felt capable to undertake their role and were involved in all aspects of client care. On the day of the visit there were three clients in at the time and there were five staff plus the manager of duty. Observations made during the visit confirmed that staff practices followed the principles of equality and diversity in order that no client was disadvantaged in any way. Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls in the management procedures could result in the needs of the clients not being met. EVIDENCE: The manager who is also the owner of the home has many years experience in the field of mental health and is a qualified psychotherapist. She has gained NVQ level 4 in Care and was waiting for confirmation of the starting date to undertake the Registered Managers Award. The manager stated that since the unit manager had left a lot of the records and documentation had been found that had not been completed correctly and she was now in the process of working through all records and procedures to correct this to ensure that needs of the clients continue to be identified and Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 24 met. Discussions took place in regard to the way in which information was collected and recorded, which in some instances could be made simpler to ensure that records are completed fully. Policies and procedures were in place for the health and safety of the clients of which staff are required to read, however the manager was reminded that this should be followed up by all staff receiving mandatory training in health and safety issues for the protection of the clients. Regular staff and client meetings form the process in which the views and opinions are voiced to ensure that a good service is provided to meet the needs of the clients individually and as a group Questionnaires that have been sent to the home by CSCI (Commission for Social Care Inspection) were seen to be available for people to complete if they wish, however there was no other system in place for monitoring the quality of the service provided. This was discussed with the manager, who agreed to give this consideration Staff spoken to said that they were well supported and felt valued. Comments received prior to the visit indicated that care professionals had successful experiences with the home and had a favourable impression of the service. They found that the management and staff had been very helpful and informative at all times. However one person whilst being positive in the main had requested clarification in regard to the alternative therapies provided and to date had not received any reply. The manager was advised to rectify this situation in order that the positive opinions being received in relation to the service provided could be continued. Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 2 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 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 2 x 2 2 x Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 26 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 YA3 Regulation 14 (1) (d) Requirement Timescale for action 31/07/07 2 YA20 13(2) 3. YA34 19 (1(b) Before any client is admitted to the home they must receive confirmation in writing that the home can meet their assessed needs. (Timescale of 16/03/07 not met). A record must be kept of all 31/07/07 medication received and disposed of to ensure that there is no mishandling and residents are protected by the procedures in place. The home’s recruitment 31/07/07 procedures must ensure that all documentation required by the regulations in respect of any persons working at the home has been obtained prior to appointment to ensure that only suitable people are employed Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 5 6 Refer to Standard YA32 YA35 YA37 YA39 Good Practice Recommendations Training should continue to ensure that 50 of care staff achieve a minimum of NVQ level 2. Induction, training and staff development should be developed to ensure it meets with the Skills for Care Council standards. The registered manager should achieve the required management qualification. An effective quality assurance system should be developed in order to measure that success of the home in meeting the aims and objectives and client goals. All documentation should be reviewed to ensure that it can be clearly understand and completed fully in order that the needs of the clients are identified and met. Staff development should address the mandatory training required to ensure that the health and safety of the clients is met. YA41 YA42 Column Care Ltd DS0000066398.V338018.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@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 Column Care Ltd DS0000066398.V338018.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!