Inspection on 15/08/07 for Daleholme

This inspection was carried out on 15th August 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Daleholme 23/08/06

Daleholme 09/01/06

Daleholme 12/07/05

Daleholme 16/11/04

Daleholme 15/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Daleholme Station Road Settle North Yorkshire BD24 9AA Lead Inspector David White Unannounced Inspection 15th August 2007 09:00 Daleholme DS0000007872.V343670.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 Daleholme DS0000007872.V343670.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. Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Daleholme Address Station Road Settle North Yorkshire BD24 9AA 01729 825769 F/P 01729 825769 info@st-annes.org.uk www.st-annes.org.uk St Anne’s Community Services 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) Sean Martin Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered for 5 Service Users with Learning Disabilities some or all of whom may also have Physical Disabilities Persons in the category of LD (E) are restricted to current service users who reach that age whose needs can still be met within this service. Date of last inspection 23rd August 2006. Brief Description of the Service: Daleholme is a care home registered by St. Annes Community Services to provide personal care and accommodation for up to five adults with learning disabilities some or all of who may have physical disabilities. The home consists of a purpose built, detached bungalow situated on a busy road on the outskirts of the market town of Settle. The town is within easy walking distance of the home and has numerous and varied facilities including shops, cafes, churches and pubs. All five bedrooms are for single accommodation, one of which has en-suite facilities. Shared areas consist of a kitchen, a dining room/lounge and a conservatory. It also has a separate well-equipped laundry. The home has a garden area to the side and rear of the premises with an area of hard standing for parking to the front. There is level access to the home. The fees at the time of the site visit on 15th August 2007 range from £211.20 to £1153.23 per week and do not include costs for hairdressing, chiropody and activities. Current information about services provided at Daleholme is available in the form of a statement of purpose and service user guide that is available in other formats and explains the care and services on offer at the home. The home has a copy of the most recent inspection report on display and copies can be made available on request to the manager of the home. Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • Reviewing information that has been received about the home since the last inspection. Information provided in an Annual Quality Assurance Assessment (AQAA) by the registered manager of the home. Comment cards received from one person who uses the service, a relative, three health care professionals and another person who has involvement with the home. This report follows an unannounced site visit undertaken on the 15th August 2007. This visit was carried out by one Regulation Inspector and took 5 hours with 4 hours preparation time. Time was spent talking to one person who lives at the home, three care staff, the deputy manager and the manager. The people living at the home have communication difficulties and observations took place of the interactions between them and the staff team. Records relating to people living at the home, staff and the management activities of the home were inspected. During the visit care practices were observed, where appropriate, and time was also spent watching the general activity in the home. This helped in gaining an insight into what life is like for people living in Daleholme. The registered manager of the home was available for some of the inspection and the findings were discussed with him at the end of the site visit along with the St Anne’s service manager for the home who was visiting the home at this time. What the service does well: People living at the home receive good standards of care from a committed, caring and well trained staff team who have a good understanding of their needs and who act in their best interests. A relative and a health professional both made comments that the home provides an “excellent service”. Each person who lives at the home is encouraged to make their own choices and to be independent so that they have control over their own lives. People living at the home have involvement in a range of activities to help with their personal development and to enable them to pursue their interests and hobbies. Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 6 The home has a car and people who are living at the home have their own train and bus passes. This enables people to go out and have easy and cheap access to local transport services. Staff are respectful to people who are living in the home and this helps to maintain the person’s dignity when receiving support from staff. The home has good relationships with local health care services so that people with any health problems receive support promptly. The atmosphere in the home is relaxed and welcoming and this helps people to feel comfortable and safe. A relative said that the home has a “homely atmosphere and a person who has involvement with the home said that staff are good at providing a “relaxing” environment so people living in the home feel at ease. The home is run well so that people’s concerns are properly addressed, good standards are maintained and their best interests are put first. What has improved since the last inspection? 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. Daleholme DS0000007872.V343670.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 Daleholme DS0000007872.V343670.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Proper pre-admission procedures are in place so that people who are thinking about moving into the home can feel confident that their needs will be met by the staff team. EVIDENCE: The home has a range of information that details the services on offer at the home. This information is given to the people living in the home and to others who may be thinking about moving into the home to help them to decide if the home is able to meet their needs. The home has a pre-admission policy that outlines the procedures to be followed when people are considering moving into the home. There have been no admissions since the previous inspection visit, however, proper preadmission procedures have been followed in the past to make sure that only suitable people are admitted to the home. Information about the person’s care needs is collected from all available sources such as the placing authority to support the home in their decision making about whether they have the skills and resources to meet the person’s needs. People who are thinking about moving to the home are invited to visit the home and have a trial period before Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 9 a decision is made about whether they move into the home on a permanent basis. Each person has a licence agreement explaining the terms and conditions of their stay at the home. The records show that the person where possible or their representatives have signed the agreement. Daleholme DS0000007872.V343670.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 and 9. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People using the service are encouraged to be independent and to make their own choices whilst taking into account any risks that need to be considered. EVIDENCE: The home has introduced new care planning documentation so that each person has a very detailed and informative person centred plan which places emphasis on how they wish to be supported in meeting their aims and objectives. This takes into account personal choices about each person’s preferred daily routines. Other areas of information include such things as “what’s important in my life, things I like doing and my food likes and dislikes”. This helps in making sure that people are able to live their lives to suit their individual needs. The care plans are well organised, detailed, and easy to follow and focus on developing the person’s independence and strengths. Care plan reviews are taking place on a regular basis and involve relatives and Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 11 others who have involvement in the person’s care. The home regularly reviews each person’s needs so that any changes can be addressed promptly. One person who lives at the home said “I can do my own thing” and this could be observed at the time of the visit. Staff encourage people to make their own choices and support them with this. Some people who live at the home have communication difficulties and have difficulty in expressing their needs through verbal means. Some staff have received “Intensive Interaction” training to help in their communication skills with people who have communication difficulties and staff said that this training had been “very useful”. The home has links with a speech therapy service, psychology and the local community health teams who provide specialist support in assisting people with their communication and emotional needs. A range of good risk assessments is in place to encourage people’s independence and safety. The assessments show how decisions have been made where people who are using the service could be restricted. These are regularly updated so that staff are clear about the actions that need to take to support people safely. A comment card from a health professional said, “the home is good at managing the needs of people with complex behaviour”. Daily records are kept up to date to reflect the cares that are being provided. Daleholme DS0000007872.V343670.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, 15, 16 and 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People who use the service enjoy a lifestyle that suits their personal needs. EVIDENCE: People living at the home have opportunities to enjoy a range of activities that are on offer. Most people attend a local resource centre where activities such as dancing, bowling and tai chi take place and another person attends a local college. People at the home have involvement in the local community and enjoy going swimming, shopping, walking and pub lunches. One person said they preferred to spend their time in the home and could do this without feeling pressurised to go out. The home has a car to assist people with their transport needs and each person has a Dales rail card and a local bus pass to enable them to have cheap and easy access to the local transport services. Four of the five people who live at the home have had a holiday this year. The Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 13 other person prefers to go on day outings and these are being arranged to suit their wishes. People are encouraged to maintain their relationships with families and friends and can see them whenever they want. In one person’s case a family member had accompanied them along with a member of staff to go on holiday. A person who lives at the home made comments that the meals “are very nice”. Meals include vegetarian, low fat and ethnic options and there is always an alternative meal available if someone does not like what is on offer. The home has introduced pictorial aids to help people with communication difficulties to have more choice in the menu planning. At the time of the site visit a mealtime could be seen to be relaxed and unhurried. Daleholme DS0000007872.V343670.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 and 20. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People’s personal and health care needs are well met and regularly monitored. EVIDENCE: Each person’s personal plan describes how support is to be given in a way that suits the person’s preferences. People could be seen to be receiving support in a sensitive and dignified manner. One person living at the home said that they always feel that their privacy is maintained and that they receive personal support in a way that “doesn’t embarrass me”. One health professional made comments that “individuals are treated with respect and have a good quality of life”. Another one said, “the home provides a warm and caring environment from staff who provide excellent cares and care is provided in a very sensitive way”. Each person at the home has a local General Practitioner, a dentist and access to other health care professionals. Referrals to specialist services are made as required and staff support people in attending appointments as could be seen at the time of the site visit when a member of staff was accompanying one Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 15 person for an hospital appointment. Health records are well maintained and up to date so that staff are clear about any actions that they may need to take. A health professional made comments that “carers do well and follow plans”. Staff are quick to respond to people’s health needs. One person has epilepsy and all staff have received training from a specialist so that they can administer medication promptly to manage any seizures. A health professional made comments that the home “provide expertise in the first aid management of seizures”. Each person has regular checks of their personal health from the practice nurse at the local surgery. Proper medication systems are in place in the home. There has been a recent incident in the home in which a medication error occurred and someone was given the wrong medication. Proper procedures were followed quickly in response to this to make sure that there were no health risks to the person receiving the medication. Measures have been put in place to reduce the risk of this error happening again. None of the people living at the home are able to administer their own medication. Staff who administer medication have all received appropriate training to be able to do this. Regular medication reviews are carried out by the GP. Daleholme DS0000007872.V343670.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 and 23. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People’s concerns are listened to and acted on properly to safeguard them from harm. EVIDENCE: The home has a detailed complaints procedure and regular house meetings take place to enable people living at the home to raise any concerns. Because some people have communication difficulties staff did say that they observe people’s behaviours and would report any signs of dissatisfaction. Since the previous inspection visit there has been no complaints made about the home. Policies and procedures are in place to safeguard people from abuse and staff have a good understanding of these. Since the previous inspection visit there has been one alleged incident of abuse. Proper procedures had been followed in response to this so that the matter was referred to the correct authorities. Following an investigation into the alleged incident a member of staff was dismissed. All staff receive regular training in abuse awareness so that they are clear about the actions they need to take if abuse is suspected or had occurred. Individual risk assessments are in place to identify and minimise any risks from a person’s behaviour. Staff do receive some training to teach them deescalation techniques so that they learn skills in how to calm down situations. St Anne’s is developing closer links with the British Institute of Learning Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 17 Disabilities (BILD) to provide more specialist training and advice in this aspect of care so that staff in all of their homes have a better knowledge and understanding of how to manage behaviour that challenges the service. Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People using the service live in a homely, comfortable and safe environment. EVIDENCE: The home is a bungalow so all accommodation is on one floor. There is ramped access to and from the home making it suitable for people with mobility problems to be able to live there. Bedrooms are personalised to suit people’s own tastes. They are spacious and a person living at the home said that he is “very satisfied” with his accommodation. A relative also made a comment about the “homely atmosphere” and another person who visits the home said that staff are “excellent at creating a relaxed and homely environment”. The home has a combined lounge and dining lounge where people eat, a domestic sized kitchen and a conservatory. People who choose to smoke can do so in the conservatory although the ventilation systems that are currently in place in Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 19 this area need to be reviewed to reduce the effect of smoke fumes. People who live and visit the home also have access to the conservatory and the home needs to check that the present smoking arrangements conform to the new smoking laws. There is a separate laundry room where staff attend to people’s personal clothing and bedding. Procedures are followed to prevent any risks of infection and all staff have recently attended infection control training. The home has an ongoing maintenance programme and the kitchen has been recently re-decorated. Any refurbishment work is planned for. Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People are receiving good cares from a committed staff team who are well trained to meet their needs. Staffing levels are sufficient in meeting people’s needs through the week, however better staffing arrangements are needed on a weekend so that all people’s needs are met. EVIDENCE: The duty rotas indicate that throughout the week there usually at least three staff on duty. However on a weekend there is mainly only two staff on duty. However on a weekend there is sometimes two staff on duty. Two of the five people living at the home require the support of two staff when going out. This means that they are restricted if they want to go out on a weekend unless everyone in the home agrees to go out. A comment card from a person living at the home said “I am sometimes limited at the weekend due to the staffing levels” and a person who has involvement with the home made comments that “one to one outings are not always possible on a weekend”. Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 21 The staffing deficits were originally going to be covered by the transfer of staff from another St Anne’s community home that was due for closure. However the closure of this home has been delayed and this has left a staffing shortfall at Daleholme. Currently the existing staff team are being very flexible and working additional hours with their agreement to cover vacant shifts. Agency staff are covering other staffing deficits. Staff said that “more staff are needed” and made comments that they are working extra hours to cover staffing shortfalls which has left them feeling tired on occasions. The management of the home are trying to address this matter by advertising for two new members of permanent staff and some casual workers. Despite the staffing shortfalls there is a good atmosphere in the home and staff morale is good. Since the previous inspection visit there have been no new appointments of staff to the home. However in the past proper recruitment procedures have been followed to safeguard people at the home from possible harm. Staff receive a range of training to support them in meeting people’s needs. One member of staff said that the quality of training that has been provided has helped in improving their skills and confidence in doing the job. A health professional made comments that “staff have a positive attitude towards training” so that they are willing to learn to improve their knowledge and skills. Only two of the staff team have completed the National Vocational Qualification (NVQ) and none of the other staff are in the process of doing the NVQ programme. The management of the home are aware of this issue and are currently in discussion with training departments about re-establishing the NVQ training programme for staff. This matter has been ongoing for some time and needs resolving. Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home is run in the best interests of people living there and proper attention is given to maintaining their health and safety. EVIDENCE: The registered manager is experienced in running the home and has completed management qualifications to help develop his skills in the role. The manager is currently working part-time at the home whilst undertaking other management duties in another St Anne’s community home that is due to close at sometime in the near future. The home has a deputy manager who provides support with the leadership and management of the home. Neither staff nor people living at the home feel that the reduction in the amount of time the manager is spending at the home has had any adverse affect on how Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 23 it is being run. Staff feel “well supported” and people at the home did not have any concerns about the way the home is currently being managed. Despite his involvement with the other home staff could access the manager at any time for advice and the service manager is also available if the manager cannot be contacted. The home is run in a way that involves everyone in decision-making. Regular house meetings are held with people at the home who receive copies of the records that are taken from the meetings. Staff meetings are regularly held and staff receive supervision to support them in meeting people’s needs. Recent questionnaires have been sent out to relatives and to others who have involvement with the home and a sample of the ones returned so far are positive about the care and services on offer at the home. One relative said that the home provides an “excellent service”. The service manager makes regular visits to the home and reports on their findings so that any areas for improvement can be addressed. The home has overall got proper arrangements in place to maintain the health and safety of the environment. A random selection of the required health and safety certificates are up to date and satisfactory. All staff receive a range of health and safety training and regular fire safety testing and checks are carried out. Proper action still has to be taken to safeguard the home against risks from Legionella. The manager did say that a thermostat has been fitted to the boiler and a specialist water company had been contacted about the matter but no further action had been taken following this. Daleholme DS0000007872.V343670.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 X 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 1 33 X 34 3 35 3 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 X 3 X X 2 X Daleholme DS0000007872.V343670.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 YA32 Regulation 18 Requirement Staffing levels must be sufficient at all times in order to make sure that each person’s needs are being fully met. Timescale for action 15/10/07 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 YA24 Good Practice Recommendations The home should seek advice about whether the current smoking arrangements in the home conform to new legislation about where people can smoke. The registered provider should make better arrangements so that more staff can undertake the National Vocational Qualification (NVQ). This will help in developing the skills and knowledge of the staff team in meeting people’s needs. Improved systems should be put in place so that stored hot water temperatures are monitored and regulated in a better way to safeguard people from any risks of Legionella. 2. YA32 3. YA42 Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Daleholme DS0000007872.V343670.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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