CARE HOME ADULTS 18-65
Dairy Close 20 Dairy Close Leek Staffordshire ST13 6LT Lead Inspector
Irene Wilkes Unannounced 05 April 2005 09:30 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 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 Stationary 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. Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Dairy Close Address 20 Dairy Close Leek Staffordshire ST13 6LT 01538 386762 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Choices Housing Association Ltd Care Home 4 Category(ies) of 4 - Learning Disability registration, with number of places Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 29/11/04 Brief Description of the Service: Dairy Close is situated in the residential area of Leek. It is registered with the National Care Standards Commission as a care home for four younger adults with a learning disability. The Beth Johnson Housing Association own the property and are responsible for all building maintenance. Choices Housing Association are the care provider. At present there are four men permanently living at Dairy Close. The property is a bungalow situated in a cul-de-sac with good access to the front and rear of the building. It is of a domestic design presenting the same as the other properties around it, and therefore not standing out as a care setting. The home is within walking distance of the town centre and public transport is accessible, although in addition the home has access to a shared car for private transport. The gardens are spacious, secure and well maintained; there is a patio area with seating, tables, a barbeque and greenhouse. The inside of the property is very well maintained, homely and domestic in character. All 4 single bedrooms are large, airy, personalised and attractively decorated. Bathrooms and toilets are appropriately located throughout the establishment. Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours by 1 inspector. A full tour of the home and gardens was undertaken and all 4 service users, 1 staff member and the manager of the home (not yet registered by the Commission) were spoken to. The Line Manager for the service was also present at the start of the visit and a discussion about the plan for the visit and the new inspection report format was held with her. The manager and the service users all sat in on this discussion. There were no other visitors to the home on the day of the inspection. 3 care plans and some staff records were examined. Information was cross referenced to further confirm this evidence. Staff practice was observed throughout the inspection. What the service does well:
All 4 gentlemen living at the home said that they are happy living there and that the staff treated them very well. The home ensures that the gentlemen live fulfilling lives based on their choices of what they want to do now, and their plans for the future. The gentlemen said that the staff helped them to take part in many activities both within the house and outside in the community that they chose to do on an individual basis, and discussions with a member of staff and the records held in the home about each person confirmed this. Further discussion with the service users and direct observation at the visit showed that the men are fully involved in all aspects of life within the home. It was clear that the staff on duty had a good understanding of each person’s needs and the support that they require. The service users said that the food was very good. Individual choices are made for breakfast and lunch, and the gentlemen plan together on a weekly basis what they want for their main meals in the following week. Choice is available if on the day the selection is not wanted. The service users were seen making themselves a drink whenever they wanted to throughout the visit. Full attention is paid to the health needs of the service users. Each has a full health audit every six months when the staff talk to them about their physical and mental health and their well being is assessed, with referrals to other health services where required. All health appointments for each person are kept and records made about any follow up action.
Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 Page 6 The home has an excellent system for the safe storage of all medication, and every aspect of medication handling is good. The gentlemen said that the staff listened to them and that they talk to them about what to do and who to talk to if they are not happy with anything. The Complaints Procedure is provided in pictorial form for those who need this. The bungalow provides a lovely home for the gentlemen. It is only about 3 years old and all parts of it meet the needs of each of the men. It is spacious but homely with comfortable furniture and fittings and modern decoration. The manager has been in post for some 6 months now. She has not yet been approved by the Commission but it is clear that she has the interests of the gentlemen at heart, and all aspects of the running of the home, including care, maintenance and important areas of health and safety such as fire procedures, infection control etc. are sound. Choices organisation provide up to date training for their permanent staff that leads to a skilled workforce that in turn helps to provide a good service to the service users. What has improved since the last inspection? What they could do better:
There were 3 areas that the home must address. 2 of the service users talked to the Commission about some incompatibility issues with the newest resident. The section above highlights briefly that the service user joined the home without any real pre-planning for the move, and this also resulted in the service users living there not having a say about who was going to live with them. While some of the problems that they talked
Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 Page 7 about may resolve themselves once everyone has become more accustomed to the changed situation, a review of the placement is required with some urgency. This is needed so that the service user can make firmer plans for his daily lifestyle choices and activities should a decision be made for him to remain living at the home, and also to help support the other gentlemen. The manager reported that she has been pursing this review and the Commission requires that this remains a priority. The home has 3 staff vacancies. Although there is evidence to show that these posts have been advertised, the ‘knock on’ effect is that the home must use agency staff to cover a large number of hours. Continuing efforts need to be made to get permanent staff in place. An agency worker told the inspector that she did not have all of the statutory training in place. The home must ensure that any staff working in the home, including agency staff, have received all of the mandatory training required. The home is recommended to keep the night staff cover under regular review. The home is also recommended to keep the number of hours worked by any individual member of staff in the home (including agency staff) under review. Choices organisation must work quicker to seek registration by the Commission of any manager newly appointed by them. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, and 4 Information is provided in suitable formats to enable service users to make an informed decision about the home. Lessons have been learned from a previous emergency placement that has led to the need for proper consideration of future admissions and thorough assessment of needs being recognised. EVIDENCE: The Statement of Purpose and Service User Guide for the home provide sufficient information for current and prospective service users and other interested parties to make an informed choice about the services provided and whether the home can meet their needs. The Service User Guide is available in pictorial format as well as the written word to provide a suitable format to meet the individual needs of service users. Some amendments to the Statement of Purpose were required following the last inspection visit in November 2004, and these had been completed in draft form. Individual care plans/information files of 3 of the service users were seen. 2 of the files related to service users who had lived at the home for some time, and each of these showed that the needs and aspirations of the 2 gentlemen had been comprehensively assessed prior to them living at the home, and that all of the information gathered at assessment had been transferred into person centred plans that were regularly reviewed.
Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 Page 10 The transfer to the home of the most recent service user had not been appropriately planned. He had not been given the opportunity of visiting the home to any appropriate degree to test out whether it was suitable to meet his needs, or for the people already living there to be able to form a view about their compatibility. Whilst these issues were fully discussed at the previous inspection, the Commission remains concerned about the lack of up to date recorded information available about the service user, and also regarding compatibility issues between this resident and the other gentlemen. 2 of the long-standing residents expressed their frustration to the inspector about the placement, with 1 of them being particularly outspoken. The home has however learned some lessons from the emergency admission that was made, and the manager confirmed that she is attempting to arrange a multi-disciplinary review of the placement to discuss a range of issues linked to the placement. The Commission must be kept informed of progress. Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, and 9 The majority of service users are very involved in the planning of their lives in every aspect, enabling them to work to achieve their aspirations and goals at their own pace. This is not as evident for the newest resident, and his future needs to be reviewed and planned, with his involvement, at the earliest opportunity. EVIDENCE: Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 Page 12 The home uses the PCP (person centred planning approach) to record information about each person’s needs and personal goals. Each file showed that the service user has an individual plan of care that includes personal details, support and care required, usual daily routine, timetable of planned activities and risk assessments that had all been comprehensively completed. The plans contained specific information about the support required by each individual and showed good involvement of the residents in developing their plans. The use of the PCP process clearly evidenced involvement of the service users in making choices about their lifestyle. For example, one gentleman had been attending a local college but had decided that he no longer wished to go there, stating that he found it ‘too noisy’. He had suggested an alternative venue and there was clear evidence to show that this was being actively pursued. He told the inspector that he was happy with the progress being made to sort this out for him. His plan also stated that he wanted to visit friends and socialise regularly and the records and risk assessments showed that he was supported to do this. He said that the staff went with him and helped him to buy a drink and food at the pub. The other plan seen for a resident who had lived at the home for a long time was to the same standard, although the inspector was not able to have as full a discussion with him due to communication needs. However, he repeated many times about seeing trains and lorries and cars, which helped to endorse the information contained in his care plan regarding his volunteer work at Churnet Valley railway and attendance at a walking group etc. More current information is required for the most recent service user to show that his changing needs are being met. This gentleman is considerably older than the other residents, and whilst information on his health needs and activities that he enjoys in the home is available there needs to be wider discussions with him about his personal goals and lifestyle following his move to Dairy Close. The manager advised that she was waiting for the review of his placement before developing this further. It is clear that a decision on his future at the home is required as soon as possible and this should be followed up with some urgency. A range of risk assessments were found in place for each service user relating to their individual needs. All of the risk assessments were comprehensive and were reviewed on a regular basis. While the home does occasionally have a group house meeting that all of the gentlemen attend, the manager advised that generally she meets with the men on an individual monthly basis to discuss with them about all aspects of living at the home, and any issues that they want to raise. One of the service users said that he liked it this way. The men do however all get together on a weekly basis to collectively choose the food menus for the following week.
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The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 and 17 Service users lead a fulfilling, enjoyable and rich life with good relationships with others both within and outside the home. EVIDENCE: Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 Page 14 The use of person centred planning leads to a focus on personal development, appropriate needs led activities and community involvement, and positive outcomes for 3 of the service users were apparent. All of the service users were at home during the visit. From discussions with them, from their records and from discussion with the manager this was seen to be somewhat rare, as each of the 3 long standing residents leads a very busy life. One of the service users is particularly gifted in arts and crafts, and he attends various college classes for woodwork, pottery and art. He showed the inspector a wooden bedside cabinet, CD rack and a pottery ornament that he had made, and various pictures that he had painted were seen in the home. He talked to the inspector about his interests and about his enjoyment of life. The other service users also told the inspector about their lifestyles, about attendance at college and the adult training centre and their visits to pubs, cafes and other outings. One service user has become a volunteer at the Churnet Valley railway, as all forms of transport had been identified as of interest to him. Each of the service users had their own choices of music and films and these were a source of pride in their bedrooms. All of the activities discussed were evidenced in the person centred plans. Further plans need to be developed for the remaining service user and outside activities organised in discussion with him should a decision be made that he is to remain living at the home. The Commission did not have the opportunity to speak with relatives or others on this visit as no-one else came to visit, save the Senior Manager responsible for Dairy Close and a number of other Choices homes. The new report format was discussed with her, and the service users also joined in this discussion asking about the inspector’s role and telling her about their lifestyles. It was confirmed by the service users that they have family and friends to visit and that visitors are warmly welcomed. Records seen and a discussion with the manager evidenced this further. Staff were discreetly observed responding to the residents and enabling them to make their own choices throughout the day, including what to do with their time, meal choices and the like. The menu plans were discussed together with how the choice of meals was arrived at. The manager informed the inspector that the gentlemen collectively choose the menus for the evening meal on a weekly basis, with individual choice made daily on breakfast and lunchtime meals. The manager confirmed that they were encouraged to enjoy a healthy diet. The latter choices were evidenced as 2 of the gentlemen prepared their own breakfast during the visit, and all 4 gentlemen chose what to eat and had their lunch while the inspector was there. This was a very relaxed and sociable occasion with a range of fresh food choices made. The service users individually told the inspector that they enjoy their meals at Dairy Close.
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The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 and 21 All aspects of service users health needs are met. Their comfort and well being are at the heart of the service. EVIDENCE: Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 Page 16 Discussion with the manager and inspection of records found that service users health needs were being addressed. Service users were supported with medical conditions within the home after staff had received relevant training and advice from health care professionals. Each service user has an ‘OK Health Check’ completed every six months, when all aspects of physical and mental wellbeing are considered. Plans of care recorded where specialist support was required, and also showed evidence that this had been sought. A record was kept of all appointments and outcomes. None of the service users currently self medicate. The arrangements in place for the storage and administration of medication are commendable. Each person’s medication is stored in individual lockable lockers kept in the manager’s office, and each is colour coded. The Nomad system for medication is used. Any PRN medication (as and when required) is kept in the locker in a separate storage box, with the photograph of the service user clearly seen. The medication for all service users is reviewed with the GP on a six monthly basis, and recording systems for the receipt, administration and disposal of medicines were sound. All staff that deal with medication receive both internal training and a course of training provided by the pharmacist. All aspects of the provision of medication complied with the home’s own policies and procedures. Via the PCP process plans of action to establish the wishes of the service users at death have been drawn up, and weekly meetings are held on an individual basis using leaflets and discussion to establish individual preferences. Choices organisation provides a ‘coping with loss’ course, designed to help staff support service users in the event of bereavement. Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The views of service users are listened to and every effort has been made to help them understand how to complain if they are not happy with any aspect of the service. This has resulted in them feeling comfortable with complaining about compatibility with a new resident, and they are satisfied with the way in which this is being addressed. EVIDENCE: The home has an appropriate Complaints Procedure in place and this is available in the Service User Guide in both written and pictorial format. There have been no complaints received either by the home or to the Commission. Aspects of day to day life that may cause minor grumbles are discussed on an individual basis as they arise, and a monthly meeting regarding aspects of living at the home is held with each of the gentlemen. The service users confirmed this and there was a standard format for the discussions in place that had been completed in all instances. 2 of the service user have expressed concerns about compatibility issues with the newest resident, and they told the inspector about this. The manager is trying to arrange a multi-disciplinary review meeting about the placement. The gentlemen are all aware of this and each is satisfied with the actions being taken. At the same time the manager is trying various approaches to resolve some of the issues between the gentlemen. Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30 The home is well designed and meets the needs of the service users throughout in a homely, comfortable and safe way. EVIDENCE: The property is only 2 years old and is a 4 bedroom bungalow on a small housing development of similar properties. It is in a quiet road although the town of Leek is close by, as are a range of community facilities. There are large attractive gardens to the front and rear of the property and inside the home is maintained to a high standard, providing spacious and well decorated accommodation with quality furniture and fittings throughout the communal areas. Each of the service users was proud of their bedroom and showed the inspector around. Each bedroom was well maintained and personalised with TV’s, collections of videos and personal possessions that reflected the interests of the individual. Each service user stated how much they liked their bedroom and the rest of the home.
Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 Page 19 There is a large bathroom with over bath shower and toilet, and a further bathroom with a walk in shower and toilet. Grab rails had been fitted when the home was first occupied. Evidence was seen that the manager had ordered a bath seat for the latest resident. Each of the 3 other gentlemen is completely mobile. On discussion with the manager it was evident that dirty linen and the disposal of incontinence waste was being dealt with appropriately, so ensuring that service users are not at risk from cross infection. The washing machine has a sluice facility. Disposable gloves and aprons were seen in use. The home was clean and hygienic. Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 and 35 The home needs to address staff vacancies and to ensure that all staff working in the home are appropriately trained to meet the needs of all of the service users. EVIDENCE: A member of staff from an agency was on duty together with the manager for the home until 3pm, when 2 of the home’s permanent staff team came on duty. The manager said that there were generally 2 staff on duty during the morning and afternoon/evening shift, with 1 sleep in member of staff. The staff rotas were seen that confirmed this. The member of agency staff on duty was employed by a domiciliary care and nursing agency. Choices Housing Association contract with this agency to cover staff shortages across the organisation, with the aim of keeping the number of different staff used in any home to a minimum. The agency member of staff on duty at the visit was interviewed. She had been working at the home for some weeks and was therefore well known to the service users. She worked full time and also often covered additional shifts, leading to her working up to nearly 60 hours on occasions. She had been given a tour of the home on the first shift that she covered in the home and had
Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 Page 21 received some background information about each of the service users. The manager also showed the inspector the induction procedure that had to be completed for all agency staff that covered topics such as fire procedures, health and safety etc. Although confirming the induction that she had received at the home, it was apparent that this particular care worker had not received mandatory training in all of the areas that is required. While this should be completed by the agency employing the worker, the home is also responsible for ensuring that no-one works in the home without the requisite training. This must be addressed. A personal staff file was seen and this contained all of the required information about the worker, such as Criminal Records Bureau (CRB) check, references, training records etc. The staff rota showed that there are 3 vacancies at the home and this is why the input of agency staff is required. Although the situation has improved since the last inspection, and further advertisements were being placed, this reliance on agency staff does not provide the service users with the stable and well trained staff team that is required. In addition the high number of hours worked by the member of agency staff spoken to is not good practice, although it must be stated that the worker herself was entirely happy with the arrangement. The issue of only 1 staff member being on ‘sleep in’ duty overnight has been raised previously. It is recommended that night staffing is reviewed on a regular basis. Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39, and 42 The home is led by a competent manager who ensures that the service users’ rights and best interests are safeguarded, and that their health, safety and welfare are promoted and protected to the best of her ability. EVIDENCE: The manager of the home has been in post for approximately 6 months. She was previously the Deputy Manager. An application has now been submitted to the Commission seeking her approval as the Registered Manager. The service users and the agency staff member were all very complimentary about the manager, and excellent relationships and interaction between her and them were seen throughout the visit. The service users talked to the inspector about how their views are respected and any issues that they raise are discussed and acted upon. However, the issue of the perceived incompatibility with the newest resident was raised by 2 of the service users. This will need careful thought to ensure that all of the residents’ best interests, both the new resident and those of long standing, are appropriately considered.
Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 Page 23 Choices organisation as a whole places a strong emphasis on the health and safety of service users and staff, and the records seen at the visit showed that the manager had interpreted all guidance and followed health and safety policies and procedures appropriately in every area examined. All maintenance records were up to date, any maintenance faults had been reported and addressed, records were up to date for food probing, temperature checks etc. COSHH regulations were appropriately followed. Fire procedures (record of tests) and fire drills were up to date. The cover of the central heating boiler was falling off. It is recommended that a gas engineer is called in to look at this and to advice if this could present as a health and safety hazard. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 3 x Standard No 22 23
ENVIRONMENT Score 3 x Standard No 24 Score 4
Version 1.20 Page 24 Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 3 3 x
Score 25 26 27 28 29 30
STAFFING 3 3 3 4 3 3 Standard No 11 12 13 14 15 16 17 3 x 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 3 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 4 4 3 Standard No 37 38 39 40 41 42 43 Score x 3 4 x x 3 x Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 Page 25 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 18(1)a,b Regulation YA33 Requirement Address recruitment issues and the over use of agency staff (also a previous requirement with a timescale of 31/1/05) Ensure a review of a service user placement is undertaken and that outcomes from the review are promptly actioned The manager must ensure that any agency staff working in the home have received all mandatory training Timescale for action 1/7/05 2. 6 YA15 1/7/05 3. 35 YA19(b) 6/4/05 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 YA33.11 YA33.4 Good Practice Recommendations Keep the night staffing hours and sleep in arrangment under regular review keep the hours worked by staff on a weekly basis under regular review Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 Page 26 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dairy Close E51_E09_S41908_DairyClose_V220949_050405_Stage 4.doc Version 1.20 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!
