Inspection on 04/01/07 for Daisy Vale House

This inspection was carried out on 4th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Daisy Vale House 15/11/07

Daisy Vale House 14/03/06

Daisy Vale House 07/11/05

Daisy Vale House 06/10/04

Daisy Vale House 08/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Daisy Vale House Daisy Vale Terrace Thorpe Wakefield West Yorkshire WF3 3DS Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 4th January 2007 10:15 Daisy Vale House DS0000001442.V319130.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 Daisy Vale House DS0000001442.V319130.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. Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Daisy Vale House Address Daisy Vale Terrace Thorpe Wakefield West Yorkshire WF3 3DS 01924 822209 01924 872619 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) J C Care Ltd Mrs Diane Crawley Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th March 2006 Brief Description of the Service: Daisy Vale House is owned by J C Care, which is a subsidiary of Craegmoor Health Care. It is managed on their behalf by Ms Diane Crawley. The home is registered to provide accommodation for up to sixteen adults who have a learning disability. At the time of the inspection there were no vacancies. Daisy Vale House was adapted and extended to provide the present accommodation. It was originally a Methodist chapel. There is a good amount of communal space including a large lounge, a dining room and a quiet room. There are fourteen single bedrooms and one double. There is a well-kept garden area to the front of the home facing on to the main road and on the road parking, in the cul-de-sac. There is a designated car park, however this is rarely used as the surrounding households use the area for parking. The current scale of charges per week are between £353 and £1,079. Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk. The last key inspection was carried out in March 2006. A pre-inspection questionnaire was completed by the home and this information was used as part of the inspection process. Comment cards were sent to residents and these responses have been included in the inspection report. One inspector carried out a site visit, which started at 10.15am and finished at 6.30pm. During the visit the inspector looked around the home, observed staff and resident relationships, spoke to eight residents, four staff and the registered manager. Resident plans, risk assessments, healthcare records, meeting minutes, and staff recruitment records were looked at. What the service does well: What has improved since the last inspection? The last inspection identified that the home should have a ramp to ease access to the building for one resident. This person has since moved to a different home and therefore it was agreed the ramp was no longer required. Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 6 Staff talked about continually trying to improve the service and those that had worked at the home for a number of years said it was good to see how the home had continued to progress and this had resulted in a better quality of life for residents. What they could do better: 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. Daisy Vale House DS0000001442.V319130.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 Daisy Vale House DS0000001442.V319130.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): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Previous inspections and procedures indicate that a thorough admission process would be carried out before residents could move into the home. EVIDENCE: One resident was admitted to the home for a very short period of time during the summer. This placement was not successful and the resident moved to alternative accommodation. The manager said all the information was transferred with the resident when they moved, therefore it was not possible to look at the admission information. The manager was informed that all records must be retained for at least three years. No other residents have been admitted to the home for over six years, therefore there was very little recent evidence available for many aspects of this outcome group. The admission process was looked at during a previous inspection and all the relevant National Minimum Standards were met. Residents’ files contained placement agreements and these had details of the service terms and conditions and the cost of fees. Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 9 One resident was over the age of 65. Staff and the manager said the home was suitable and able to appropriately meet their needs. Currently the home is registered to provide care to people between the ages of 18-65. The manager agreed to apply for a variation of registration. Daisy Vale House DS0000001442.V319130.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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents are happy living at the home and they feel they are cared for well but to make sure everyone is receiving the right support and given opportunities to develop the care planning and risk assessment process must improve. EVIDENCE: Most of the inspection was spent talking to residents and staff. Every resident said they were happy living at Daisy Vale and all staff said they thought the home provided good care. Staff talked about providing individual care to each resident. Staff had good knowledge of residents’ needs and were able to talk about how they successfully treat everyone as an individual. For example residents engage in different tasks around the home and this is dependent on the wishes and abilities of each person. Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 11 Care records for three residents were looked at. All plans and assessments were in the same format and had originally been written in 2000 or 2001. The care plan and assessment document was dated annually to confirm it had been reviewed but there was very little evidence of changes taking place. At each review, goals should have been identified for the resident to work towards. One care record identified 18 goals in 2000 and apart from a change in day care these goals were still the same in Nov 2006. This demonstrates that the reviews do not successfully identify achievable goals. Another care record had a list of care needs that again had been written in 2000 and was dated to say it had been reviewed but the resident, staff and the manager confirmed that the information was out of date and had not been correct for some considerable time. For example information relating to shopping, smoking, friendships and money were inaccurate. Risk assessments were also completed on the same basis as care plans and were therefore not up to date. Some risks were identified at the inspection but assessments were not in place. These related to epilepsy and medication. A four weekly evaluation was completed by keyworkers and this was an update of anything relevant to the goals but staff only evaluated the first four goals. Therefore some goals were not reviewed and care needs were not recorded. For example staff had concerns that one resident had lost a lot of weight and even though they had taken him to the GP there was nothing in his care plan, assessment file or evaluation sheet. Another resident had restricted access to cigarettes, alcohol and money. Staff only give the resident a set amount each day for health reasons but this has not been recorded. Any limitations must be agreed and clearly documented in the plan of care to make sure residents’ rights are properly safeguarded. There was no evidence in the care plans that residents were in involved in deciding what care and support they want. One resident showed the inspector a book they had devised with staff at day services which had information about the type of help they required. They said they had not been involved in a similar process at Daisy Vale. The manager said the organisation were going to introduce a new care planning format and agreed this would be a good opportunity to start new care plans which were more resident focussed. Daisy Vale House DS0000001442.V319130.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. A good, flexible service is provided and residents have opportunities to do different things, although this could be improved if there were more opportunities to use community facilities. Residents are treated as individuals and they receive different levels of support depending on their level of need. EVIDENCE: Residents spoke highly about the home. The following comments were made, ‘it’s lovely living here, staff are friendly, it’s nice food, I’ve got good friends here, we have a laugh with staff, the holidays are good, staff are nice, I like my key worker, the manager is very, very good.’ When asked about times for getting up, going to bed and bathing, residents said they can ‘do what they want’. Residents said they could choose their own clothes, and decide when to go to their room. Comment cards were received Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 13 from eleven residents and they all stated that they make decisions about what they do. Residents had keys to their rooms and many kept them locked when they went out. Residents talked about doing different things, which included having parties, helping around the home, spending time with staff and time in their rooms. One resident talked about vacuuming and dusting and said staff helped him clean his bedroom. Another resident said she liked watching TV and talking to staff. Most residents attend external day services. One resident has a work placement, two attend college, and eleven attend day care services. Residents said they enjoyed going out during the day. Residents talked about visiting relatives and having visitors to the home. A friend of one resident and a relative visited on the day of the inspection. Daily records stated there was regular contact with families. A hairdresser, optician and chiropodist visit the home and provide an in-house service to most residents. Although this may be appropriate for some residents, others would benefit from having more opportunities to use community facilities. Staff said two residents visit a local hairdresser and they enjoy this. The manager agreed to look at increasing the number of residents that use community facilities. Three holidays were organised in 2006, a barge holiday, Blackpool and Spain. Residents talked about their holidays and said they had a good time. Holiday photographs were displayed in the home. One resident did not have a passport. A record in their file stated that there had been a problem with the application in November 2005 but there was no evidence to show that this had been followed up. The manager agreed to contact the passport office. Daisy Vale House DS0000001442.V319130.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 good. This judgement has been made using available evidence including a visit to this service. The home has systems in place to make sure residents receive the right support from healthcare professionals but additional monitoring should be introduced when concerns are raised. EVIDENCE: Staff said all residents use various healthcare services and this includes dentist, chiropodist and GP. Resident said they tell staff when they are unwell and when they go to appointments staff go with them. A health care summary sheet stated that residents had attended dental, GP, nurse and optician appointments within the last twelve months. Residents’ weight had been monitored monthly and a record was maintained. However, one resident had lost a considerable amount of weight and they had visited the GP but weight had not been monitored since November. Only the month was recorded and not the exact date, therefore it was not possible to establish when in November the resident was weighed. If concerns are Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 15 identified about the weight of a resident, an assessment/care plan should clearly state how often a resident should be weighed. Medication records were looked at and had been completed correctly. No controlled medication was held at the home. The home uses a monitored dosage system. Medication was looked at and this corresponded with the medication records. All staff that administer medication have completed medication training. Daisy Vale House DS0000001442.V319130.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 good. This judgement has been made using available evidence including a visit to this service. Satisfactory procedures are in place and residents will report their concerns to staff and management. Systems are in place to make sure residents’ finances are safeguarded. EVIDENCE: The manager said the home had not received any complaints within the last twelve months. The home has a complaint’s book to record any complaints. The complaints procedure was displayed in the main office. CSCI contact details were included in the complaints procedure. Residents said they talk to staff and the manager and would tell them if they were unhappy. One resident said she had talked to staff when she had a problem. Staff said the manager was very approachable and they would be comfortable talking to her about any concerns. Staff were also clear about reporting any concerns to the manager. The manager was familiar with adult protection procedures and her responsibility to report any concerns. She also said there had been no occasions when any form of restraint or physical intervention had been used within the last twelve months. Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 17 Financial records were looked at. All financial transactions were recorded and receipts were obtained for any purchases made. Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is pleasant, well maintained and residents are very comfortable in their surroundings. EVIDENCE: A tour of the building was carried out. All communal areas and bathrooms were visited and the majority of bedrooms were seen. The home was clean and tidy and there were no odours. Decoration, furniture and furnishings were of a high standard. There is an enclosed garden that residents freely access. Residents were keen to show their bedrooms and were very clear this was their personal space. Bedrooms were personalised and each room had a lot of items that reflected individual preferences. This is good practice and demonstrates that everyone is encouraged to make their rooms homely. Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 19 There are four main communal areas, kitchen, dining room, lounge and quiet room. The residents were using all the communal rooms and were seen to walk freely around the home. There were photographs, pictures and ornaments in communal areas, which helped enhance the homely environment. There was a supply of wipes, gloves and toilet rolls throughout the home. In most bathrooms and the laundry there was antibacterial hand wash but the manager acknowledged that residents sometimes moved these. Washable towels were used for hand drying. The provider must ensure facilities are appropriate to prevent the spread of infection. The last inspection identified that one resident had difficulty in accessing the home because of mobility difficulties, and a requirement was made for a ramp to be installed. Since the inspection, the resident has moved to more appropriate accommodation and difficulties in access no longer apply. The manager said that all residents could easily access the home and accessing the home would be assessed as part of the admission process for any prospective residents. It was agreed that the requirement was no longer relevant. Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team work well together and everyone works hard to provide good individual care but because there are often not enough staff to take residents out, therefore the home is not satisfactorily meeting the collective needs of the residents. Staff feel well supported and systems are in place to make sure everyone receives the right training and supervision. EVIDENCE: The home has a low turnover of staff and many staff have worked at the home for a number of years. Staff at the home had a good knowledge of the residents and were able to provide information about individual likes and dislikes. Staff said ‘the staff team get along, it’s a lovely team, it’s a brilliant atmosphere, it’s a nice little home and everyone has a bit of fun.’ They also said, they ‘make sure residents are happy and try to keep improving the care.’ As stated earlier in the report, residents talked very positively about staff and they obviously enjoy spending time with them. Residents said they would like Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 21 to go out more. One resident said they didn’t go out because there was not enough staff. Staff said it was difficult to go out with residents because often there were only two staff on duty during evenings and weekends, and there had to be at least three staff on duty to enable one staff to take residents out. Staff said sometimes there were three on a Saturday and this provided opportunities to go out to Castleford or Wakefield. The manager said there should be three staff on duty but because of staff vacancies and staff leave this had not been the case recently although they generally tried to have three on duty on a Saturday. The manager said it was possible to take residents out during staff change over period. Four weeks of daily records were looked at for three residents. There were only a few occasions when residents had been taken out into the community by staff. Three weeks of staff rotas were looked at. There were only two staff to cover all late shifts. Only two staff were rostered to work on all three Sundays and two Saturdays. The rotas only contained E or L to confirm staff shifts. There should be details of the hours worked so staff cover can be properly established. Only one staff member has been recruited in the last twelve months. These recruitment records were looked at and all the relevant information was available. The staff member confirmed he had a good induction programme when he started working at the home. The Pre Inspection Questionnaire and training record stated that staff had completed all mandatory training within the last twelve months. Five staff have completed NVQ level 2 or equivalent. Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management of the home is good. The manager promotes resident choice and creates a homely and relaxed atmosphere. Recording systems must improve to make sure the welfare of residents can be monitored. EVIDENCE: The manager has worked at the home for a number of years and has relevant qualifications. Residents and staff were very positive about the manager and everyone said she was a good manager. Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 23 Residents meeting minutes confirmed that residents had opportunities to put forward suggestions. They had talked about what they enjoyed and what they wanted to do. Once a month the provider visits the home and looks at the general conduct, these visits are called Regulation 26 visits. The manager confirmed the visits were completed regularly. Copies of reports from these visits should be sent to the CSCI but only three reports have been received in recent months. The inspection identified some problems with the general reporting and recording systems. There was a lot of out of date information in resident files and this was held in the same files as current information, therefore accessing up to date information was very difficult. Some records were also vague and it was not possible to establish what had taken place. For example staff used terms such as abusive and very abusive to describe a resident’s behaviour but there was no detail of what the actual behaviour consisted of. Staff also recorded ‘hygiene needs met’ or ‘personal hygiene’ in resident’s files but again it was not clear whether this referred to bathing, showering or washing. There was evidence that several incidents had taken place but incident forms had not been completed and on one occasion, a resident had hit another resident and this had resulted in a red face and eye. It is not possible to monitor events if incident reports are not completed. Two communal books were being used to record bath/showers and chiropody appointments. The information was not being recorded in individual files therefore it was not possible to track chiropody appointments or bathing through residents personal files. Communal files should not be used because it does not maintain confidentiality. As stated under the ‘Choice of Homes’ section, some records had been transferred to another home and copies were not retained at Daisy Vale. The manager must now make sure that the home maintains accurate, clear and up to date records. If this does not improve for the next inspection this area may be judged as adequate. This would mean the overall rating for the home would also change to adequate. The pre inspection questionnaire stated that policies and procedures were available and regular maintenance and health and safety checks by external agencies were completed at the home. Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 3 3 X 1 3 X Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The registered person must make sure care plans identify how residents personal social and health care needs should be met; unless it is impracticable residents should be involved in this process. This must include any restrictions that limit residents’ rights. The registered person must ensure risks to residents are properly assessed. The registered person must ensure residents have opportunities to use community facilities. This relates to hairdressing, optical and chiropody services. The registered person must make sure residents’ healthcare needs are properly monitored. This relates specifically to appropriately monitoring residents’ weights. The registered person must ensure systems are in place to control the spread of infection. This relates to hand washing facilities. DS0000001442.V319130.R01.S.doc Timescale for action 31/08/07 2. 3. YA9 YA13 13 16 31/08/07 31/03/07 4. YA19 12 28/02/07 5. YA30 13 28/02/07 Daisy Vale House Version 5.2 Page 26 6. YA33 18 7. YA33 17 The registered person must make sure there are sufficient staff working at the care home to meet the needs of residents. The registered person must make sure the staff rota identifies hours that are worked. 31/03/07 28/02/07 8. YA41 17 9. RQN 10. RQN The registered person must ensure relevant information is recorded, the information must written in individual records, be accurate and retained in the care home for at least three years. 26 The registered person must ensure the copies of the regulation 26 reports are sent to the CSCI. Care The manager must apply for a Standards variation of registration that enables them to provide care to Act; Section 15 one service user over the age of 65. 31/03/07 31/03/07 31/03/07 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. Refer to Standard YA14 Good Practice Recommendations The registered manager should ensure all residents could engage in the same group activities if they wish. This relates to assisting a resident to obtain a passport. Daisy Vale House DS0000001442.V319130.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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