Inspection on 06/07/06 for Dixon House

This inspection was carried out on 6th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dixon House 09/10/07

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Dixon House 17a Gorse Road Blackburn Lancs BB2 6LY Lead Inspector Mrs Janet Proctor Unannounced Inspection 6th July 2006 09:45 Dixon House DS0000067394.V299058.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 Dixon House DS0000067394.V299058.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. Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dixon House Address 17a Gorse Road Blackburn Lancs BB2 6LY 01254 662255 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) S.M.S CARE LIMITED Mrs Janet Phillips Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25/11/05 Brief Description of the Service: Dixon House is registered to accommodate 6 people who have a learning disability. SMS Care Ltd are the registered persons for Dixon House and the day-to-day management of the home is the responsibility of a registered manager. The house is a split level modern detached property, set in its own well established grounds, with a private garden to the rear. At the front of the house is an elevated outdoor porch area, where people may sit and look over the lawn towards the road. There are two sitting areas and a dining room, and all bedrooms are for single occupancy. Parking is available at the front of the property, at the side of the driveway, or on the road. Dixon House is located close to bus stops with easy access into Blackburn via regular bus services. Blackburn provides most facilities and services, with bus and train routes being available to other towns or cities. The home has a Statement of Purpose and a Service User’s Guide that tells prospective residents about the home. The current fees are £479-00 to £52000. Residents are responsible for paying for their own leisure activities, holidays, hairdressing and clothing requirements. Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over one day on the 6th July 2006. The previous inspection was done on 25th November 2005 and information on the findings of this can be obtained from the home or from www. CSCI.org.uk. No additional visits had been made to the home in-between these times. On the day of the inspection there were 6 residents accommodated at the home. Information was obtained from staff records, care records, and policies and procedures. Information was also got from talking to 3 service users and one of the registered persons who was also working as a member of the staff team. Four residents’ survey forms were returned. Wherever possible the views of residents were obtained about their life at the home and their comments are quoted in the report. What the service does well: Residents were encouraged to be as independent as possible. If they were unable to be independent, staff gave support and assistance. One resident said, “I go to work 4 days a week. I go on my own. I feel safe doing that. I go into town on my own on Saturday and look round the shops.” The privacy and dignity of residents was protected. A resident said, “Everyone has to knock on the bedroom door and wait for you to say come in before they go in.” Residents were involved in making decisions about the way the home was run and about their own lives. They said, “They ask us where we’d like to go. We had a meeting – we’re able to say what we want” and “ We have a meeting to decide what we’re going to do. You can say what you want.” All of the survey forms returned said that the residents felt they made decisions about what they do. Dixon House provided each resident with their own room. They could personalise this to their own taste. This meant that the residents lived in nice, homely and comfortable surroundings with their own things around them. A resident said, “I clean my own room. I like living in this house. I like my bedroom.” All of the survey forms returned said that the residents felt that the home was always fresh and clean. Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The Service User’s Guide must have a copy of the contract in it. This is so that anyone who is thinking about living at Dixon House will know what the terms and conditions of residency are. There must be a record of the personal allowance for each individual resident and how this has been spent. This is so that it can be seen that residents are Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 7 receiving their full amount of money allocated to them and that it is being used in their best interests. The recruitment procedures must include the taking up of two written references. One of these must be from the last employer. This is so a decision can be made that they are suitable to work with vulnerable adults. There must be record of the Induction training given to new employees. The Induction training should comply with the 12-week Common Induction standards. Training for all staff in safe working practices must be arranged. All staff must receive training in: Fire Safety; First Aid; Protection of Vulnerable Adults; and Basic Food Hygiene. Staff members who give out medication must receive proper training in this. More staff should be enrolled on the NVQ in care course. Supervision for care staff must be done. This is so that it can be shown that staff are trained, have the skills and abilities to undertake their work, and are supported to do this. The registered persons must develop some quality assurance systems. This is so that they have a way of looking at the service they provide and whether this is the best way of doing things. 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. Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was sufficient information to allow prospective residents to make an informed choice about whether they would like to live at Dixon House. Procedures were in place to ensure that any new resident had their needs assessed before coming to live at Dixon House. EVIDENCE: There was a new Statement of Purpose and Service User’s Guide, which was called a welcome pack. These gave details about the home and what services were offered. There was no copy of the contract and no details of useful addresses in the Service User’s Guide. No new residents had been admitted since the previous inspection. The manager was aware of the correct procedures for ensuring that needs were assessed before anyone was admitted to the home. Dixon House DS0000067394.V299058.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The plans of care had current information on the residents’ needs. Residents were allowed to make decisions about their lives and any risks were assessed and minimised. EVIDENCE: Each resident had an individual care plan folder. A new style of documentation for care planning had been started. There was an assessment of the resident’s daily living abilities. The plan of care identified the need and the actions to be taken by staff. The description of the needs stated both the strengths and the weaknesses of the resident. This meant that staff had the information they needed to be able to build upon existing strengths whilst assisting residents. All of the needs sheets had been signed by the resident and the Manger was also making appointments with parents to discuss the care plans. There was a comment sheet for the resident or their family member to complete so that they could state their views about the plan. Minutes of the residents meetings showed that they had been involved in decisions about activities. The range of activities had been described and they had made choices from these. There was no information available on how to Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 11 contact advocacy services. This meant that staff, residents and visitors may not know how to get help for the resident in making decisions about their lives. The residents managed small amounts of money on a daily basis. The records seen showed the Daily Living Allowance and personal allowance due to each resident. However, these records did not show the allocation to each individual resident, as the money was used as a central fund. This meant that some residents may be subsidising others. There was a description of the money that had been withdrawn e.g. for bus fares, entertainment etc. Risk assessments were completed for travelling alone. These showed that the residents had been assessed as safe to do so. Some safeguards e.g. escorting to bus stop had been put in place. Action would be taken if a resident did not return home within a certain time period. There was a missing persons procedure for staff to follow should this happen. Dixon House DS0000067394.V299058.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 , 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents engaged in a range of activities that met their social and recreational needs and relationships with family and friends were encouraged. The rights of residents were respected through staff encouraging decision-making and individual choice. The meals served were healthy and were to the liking of residents. EVIDENCE: All of the residents had some sort of part time job that raised their selfesteem. Residents spoken to said they enjoyed going to work and meeting the other people that worked there. One of the residents had just finished a course at College. Residents had access to Lifelong Learning through the Gateway club. Some residents had certificates to show the learning they had done. Residents’ likes, dislikes and interests were noted in the plan of care. The range of activities on offer to residents had increased and now included swimming and gym membership. Activities were done at week-ends and in the evenings. The residents did not all have to do the same thing at the same time and could make a choice about whether they joined in or not. All of the Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 13 residents had their own DVD players and TVs and there were games, jigsaws and puzzle books seen in the home. Friendships with others outside of the home were encouraged. One resident had a friend who she exchanged visits with. Residents could see visitors in their own room if they wished. All residents had contact through work with people who were not disabled. All residents had regular contact with their families. Privacy and dignity was respected, both by staff and by other residents. Bedroom doors had locks but no one held a key for the door and there was no rationale for this. Residents took responsibility for cleaning their own rooms and helping with household tasks. This was not defined in the plan of care. Residents were no longer expected to purchase and prepare all their own meals. Four times a week there was a meal prepared by staff and all the residents sat down ‘family style’ to eat. Whilst residents could choose not to join in if they did not wish to all of the residents spoken to said that they enjoyed this style of meal. The residents decided what they would like to eat and staff prepared it. There was more emphasis on fresh fruit and vegetables. Flavoured water was available and residents were encouraged to drink this instead of pop. This meant that the diet was now more nutritious. Drinks and snacks were available. Residents were encouraged to help with setting tables, clearing away and wiping tablemats. There was a rota on display for this. There was no record of individual meals taken when residents made their own meal. There was no record of fridge and freezer temperatures. These were taken but not recorded. Dixon House DS0000067394.V299058.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ personal care and health needs were met. The management of medication within the home had improved but was not fully safeguarded as not all staff had received training. EVIDENCE: The plans of care gave details of any assistance needed with personal care. These details included the level of observation and any prompting needed. If there was a preferred style of dress or hairstyle this was also noted. Personal care was done in private. There was both male and female staff employed so there was some ability to have own gender assistance. There were flexible rising and retiring times, although some residents needed to be up at specific times because of work commitments. It was evident that residents were allowed to express their own style of dress. Health needs were also covered in the plan of care. These details included any specific illness or condition suffered by the resident. Appointments with the GP were recorded. Access to other specialists was noted. For example: chiropodist input; dental appointments; and audiology appointments. None of the residents managed own healthcare. Staff escorted them to the GP and the resident could see the GP alone if they wished to. Risk assessments were done Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 15 for moving and handling. None of the residents had a need for pressure sore risk assessment. None of the residents managed their own medication and there was a medication assessment in the plan of care. Medication management training was in the process of being arranged for all staff. New and updated policies and procedures were being written. There was a homely remedies policy and a letter from each GP authorising administration if needed. Medications were stored in a locked cupboard in the kitchen. There were no Controlled Drugs. There were records of medications ordered and a record of medications returned. There was a record of all medications administered. There was a photograph of the resident on the chart for identification purposes. Any handwritten entries to the charts were signed and witnessed. Medications were not rewritten when the directions changed. There was no criteria for when ‘as required’ medications were to be given. This meant that they might not be given in a consistent manner. Parents were now signing for the medication taken on home leave when they received this. There was no record of what was returned when the resident came back to Dixon House. This meant that there was not a complete audit of the use of medications. Dixon House DS0000067394.V299058.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents felt that their views were listened to and acted upon. Training for staff in Protection of Vulnerable Adults was needed to ensure that residents were fully safeguarded and protected from abuse. EVIDENCE: There was a complaints procedure on display. This stated that all complaints would be acknowledged between 48 hours to 7 days. There was no time scale for when a response would be given. The procedure had the CSCI contact details. The procedure stated that an advocate or other person could be used by the resident to help them express their views. It assured the complainant that they would not be victimised for raising a complaint. There was a resident friendly procedure seen in the bedrooms. This explained the procedure in simple words and some pictures. There was a form for recording any complaints received. No complaints had been received by the home or the Commission. The Blackburn with Darwen Borough Council abuse leaflets were seen in the home for staff to read. The training in Protection of Vulnerable Adults had not yet been done by staff. Places on the next course had been applied for. There were Protection of Vulnerable Adults and whistle blowing procedures available. These needed to be made more specific to Dixon House. None of the residents had a history of aggressive behaviour. Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lived in a safe, clean and homely environment that met their needs. EVIDENCE: The home was clean and tidy throughout and decorated and furnished in a homely manner. Some changes had been made to the entrance hallway making this more of a reception area. The proposed redecoration and refurbishment of the home had been discussed with residents at their meeting and their opinions and suggestions noted and acted upon. There was a maintenance schedule that showed what was planned and what had been done. The residents had the choice of two lounges. The first floor lounge was to be decorated and new sofas had been ordered and new blinds purchased. There were sufficient bathrooms and toilets for the use of residents. The gardens were tidy and maintained. Each resident had a single bedroom. These were personalised to their own individual taste – with wall posters, furniture and personal possessions such as a Karaoke machine. A resident’s bedroom had been fully redecorated and new flooring put down. She had been fully involved in picking the colour scheme. Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 18 There was a separate laundry area that could be reached without going through food storage and preparation areas. The floor and walls were easily cleanable. There was a domestic style washer and dryer and facilities for ironing clothes. Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staff at the home did not have enough training, qualifications or supervision to show that they were competent to care for and could meet residents’ needs. The recruitment procedures were not thorough and did not fully safeguard residents. EVIDENCE: Due to the registration of new providers there has been 100 turnover of staff since May 2006. This meant that none of the 5 care staff now employed had the NVQ qualification. One member of staff had commenced the course. There was a copy of a duty roster available for inspection. These showed the name of the staff and the hours they were to work. Additional staff were on duty for periods of higher activity. The rotas did not always show which staff member was on sleep-in duty during the night. There were both male and female staff members. Staff meetings were now being held and minutes were available for these. The files for two new employees were viewed. These showed that an application form was completed. The manager had now redesigned this form so that it showed the reasons for leaving previous employment. There was proof of identity. There was an equal opportunities form signed. Criminal Record Bureau checks and POVA First checks had been done before the Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 20 employee started work. There were no references on file. The manager did not have any copies of the General Social Care Council’s code of conduct to give to staff. This meant that they did not have details on their professional responsibilities. There was no evidence on file that staff had been issued with a contract. Arrangements were being made for all staff to attend training courses. The manager was starting an individual training file for each member of staff to show what they were aiming for and had done. The manager and one member of staff had recently done diabetes awareness training. The manager was not aware of the amount in the training budget. This is needed so that she can plan training that meets needs but also stays within the budget. New employees had been shown emergency details, for example, fire safety and about medical emergencies. This had not been documented. There was a list of issues to be covered in the Induction period. Formal supervision of staff had not yet commenced but the manager was intending to start this in the near future. She had developed a form for recording the supervision. Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 and 43. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was a competent person in charge of the home. Quality assurance systems were needed to ensure that the home was run in the best interest of the residents. Health, safety and welfare of residents and staff was not fully safeguarded as not all staff were trained in safe working practices. EVIDENCE: A new registered manager had been in post since March 2006. She has the relevant qualifications and experience for her role and responsibilities. An annual development plan and business plan had been formulated as part of the registration process. This showed the priorities to be addressed over the coming year. There were few quality assurance systems to enable the manager to identify any shortfalls in care and management. Residents’ meetings were held as a means of obtaining views and opinions. These were acted upon if possible. Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 22 Residents’ surveys had also been commenced but the results not yet published. The views of relatives had also been sought. This had been done at the time of the new providers taking over the home and showed some unsettled feelings. The manager intended to redo the survey later this year as a way of finding out if the relatives felt that things had improved. Management meetings and staff meetings were held. Minutes were kept of these. There were policies and procedures available for staff. The manager was in the process of reviewing all of these and updating them so that they were specific to Dixon House. There was a resident friendly fire procedure. A fire drill for staff and residents had been done in May 2006. The fire alarms and emergency lighting were tested weekly to ensure that they worked correctly. Servicing of gas and electrical appliances was done. Residents had a thermometer to ensure that the bath water was the correct temperature. There was no record of the testing of water temperatures to ensure that the thermostatic mixing valves were working correctly. Training in all safe working practices was needed for all care staff. The manager was aware of this and was actively looking for courses. Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 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 2 34 2 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 1 3 Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 24 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 2 3 Standard YA1 YA7 YA17 Regulation 5 Schedule 4(9)(a) Schedule 4(13) Requirement There must be a copy of the contract in the Service User’s Guide Allowances**** Timescale for action 31/07/06 31/07/06 31/07/06 4 5 6 7 YA20 YA23 YA34 YA35 8 9 YA36 YA39 There must be a record of the food provided to residents. This must include details of the meals that they prepare for themselves. 13(2) All staff who administer medication must receive accredited training. 13(6) All staff must receive training in Protection of Vulnerable Adults. 19 Two written references must be obtained prior to a member of staff starting work. 18(1)(c)(i) There must be evidence to show that each member of staff has received training appropriate to the work they are to perform. This must include: Fire Safety; First Aid; Protection of Vulnerable Adults; and Basic Food Hygiene. 18(2) There must be supervision given to all staff. 24 Quality assurance systems must be introduced so that there is self-monitoring of the service. DS0000067394.V299058.R01.S.doc 30/09/06 30/11/06 07/07/06 30/11/06 31/10/06 30/11/06 Dixon House Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations Standard 1 YA1 There should be information on how to contact the local social services and Primary Care Trust in the Service User’s Guide. Other useful addresses e.g. advocacy service and MIND should also be included. 2 YA7 There should be information on how to contact the advocacy service. This should be available to staff, residents and visitors. 3 YA16 There should be information in the plan of care as to why the resident does not hold a key to their bedroom door. 4 YA16 The fact that residents take responsibility for housekeeping tasks should be included in the Service User’s Guide and their individual plan of care. 5 YA17 A record of the fridge and freezer temperatures should be available. 6 YA20 The details of medication should be rewritten on the chart if the direction change. 7 YA20 There should be criteria for staff to consult so that they know the circumstances when to give ‘as required’ medication. 8 YA20 There should be a record of the medications returned when a resident comes back from home leave. 9 YA22 The time for when a complainant can expect a written response should be added to the procedure. 10 YA23 The Protection of Vulnerable Adults and whistle blowing procedures should be made more specific to Dixon House. 11 YA32 50 of the care staff should have NVQ level 2 or equivalent. 12 YA33 The duty rota should show which member of staff is doing the sleep-in duty. 13 YA34 All new staff should receive a copy of the GSCC code of conduct and practice. 14 YA34 All staff should receive a contract stating their terms and conditions of employment. 15 YA35 The manager should be aware of the amount of money available for training needs. 16 YA35 A record should be made of the issues covered in the first day induction. The remainder of the induction period should comply with the issues specified in the 12-week common induction standards by Skills for Care. 17 YA42 Regular testing of the hot water temperatures for baths and showers should be done. Dixon House DS0000067394.V299058.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Dixon House DS0000067394.V299058.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. 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!