Inspection on 19/01/07 for Don View

This inspection was carried out on 19th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Don View 12/11/08

Don View 30/11/07

Don View 03/11/05

Don View 01/11/05

Don View 24/08/05

Don View 07/07/04

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 MIXED CATEGORY MAJORITY OLDER PEOPLE Don View 22 Thellusson Avenue Scawsby Doncaster South Yorkshire DN5 8QN Lead Inspector Ian Hall Key Unannounced Inspection 19th January 2007 09:00 X10029.doc Version 1.40 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 Don View DS0000031838.V327841.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 Older People and 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. Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Don View Address 22 Thellusson Avenue Scawsby Doncaster South Yorkshire DN5 8QN 01302 785257 01302 789457 NONE NONE Doncaster Metropolitan Borough Council 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) Post vacant Care Home 25 Category(ies) of Learning disability (25) registration, with number of places Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The support of a day care centre must not impact on the staffing needs of Don View. There must be no removal of staff from the home’s rota to meet a shortfall in the day centre staffing or to meet needs of the persons who reside in the independent living house. Wheelchair dependent service users must be allocated private bedroom accommodation that has 12 square metres of useable floor space. The home is registered to admit service users over the age of 50 years. 2. 3. Date of last inspection 3rd November 2005 Brief Description of the Service: Don View is a care home that provides personal care for up to 25 persons who are aged over 50 years with a learning disability. The majority of service users are aged between 50 and 65 years the remainder are aged over 65 years. The home is owned and managed by Doncaster Metropolitan Council (DMBC); it is situated in the small community of Scawsby which is approximately 4 miles from Doncaster. It is easily accessed from the A1M with frequent bus services stopping a short distance from the home. Adequate car parking spaces are available with unlimited on street parking within the quiet residential area. The home is well integrated into the local community. The home was built in the late sixties. Don View is a three-storey building with staircases to all floors. There is lift access from ground to the first floor. The second floor is accessed by means of a short staircase. All service users are accommodated in single bedrooms. Toilets and bathrooms are readily accessible on each floor. The dining area is located on the ground floor adjacent to the kitchen. There are several lounge areas located on both the ground and first floor, their use is varied and distinct: TV/music lounge, quiet lounge and smoking lounge. Each floor has level access throughout with handrails and wide corridors. The home is set within its own grounds and well-maintained gardens. There is a large sheltered easily accessible patio/barbecue area that is popular with service users. Unregistered day-care and sheltered housing is provided within the grounds of the home. Information gained on the 19th January 2007 indicated the current fees were £330.00 for residential care with additional charges are made for holidays, Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 5 hairdressing and chiropody. These fee charges only applied at the time of inspection, more up to date information may be obtained from the manager of the home. Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that started at 08:00am and concluded at 14:20pm on the 19th January 2007. The inspection included a tour of the building, reading records, discussions with staff and service users, observation of service users, and observation of the meals provided. The inspector also met with the acting manager, deputy manager and other members of staff. What the service does well: 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. Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): OP 2, 3, 6 and YA 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had written information about the service for potential service users and their relatives. Assessments of service users had been made prior to them moving into the home, ensuring that staff were able to meet their needs. The staff team had received a range of training to ensure that they understood the needs of service users. Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 9 EVIDENCE: Three service user case files were examined and were found to lack copies of individual contracts detailing terms and conditions to provide service users with information about the standard of service they can expect to receive. Each service user case file contained a detailed needs assessment; this included all areas of daily living and included personal care, health care, social interests and areas of risk when appropriate. Service users had been involved in their assessment and their wishes and views taken into account before they made the decision to live at Don View. Copies of social work referrals and assessments were available and kept on the case file. Intermediate care is not provided at this home. Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service Users, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and YA 6, 9, 16, 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were plans in place to identify what help and support service users needed. They appeared well cared for and their care plans indicated that health and personal care needs were identified. Service users felt that the staff treated them with respect and kindness. The medication system was well managed with policies and procedures in place to guide staff and protect service users. Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 11 EVIDENCE: Care records contained individual needs assessments with plans of care for staff to follow and meet each individuals needs. These records were correctly maintained; they described how each resident responded to the care provided and any necessary changes that were made. These were monitored at regular intervals; some plans had been amended within the timescale in response to changing needs. Areas of risk such as risk of falling had been identified with detailed plans made to protect service users. One service user had been assessed for his ability to travel to town, spend a prolonged period alone and return safely at the end of the day. The home facilitates access to the whole range of health care professionals. All service users are registered with a general practitioner and the registered manager reported that there is a good relationship with the doctors. Records are safely maintained in accordance with DMBC policy and procedure protecting service users personal information. Several service users were facilitated to self medicate to maximise their independence. Staff had received additional accredited medication training for the administration and management of medicines to ensure safe practises are followed. Staff were observed dispensing medications and assisting service users to take them in line with safe practise. Policies and procedures for staff guidance were available and had been reviewed to ensure they are meet current standards for safe practice. Service users spoken with stated they were happy living at Don View and that staff were very good and always helped them. Staff were observed to knock on bedroom doors and wait for a response before entering the room. Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 and YA 12, 13, 15, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users felt that suitable activities were provided at the home to keep them stimulated, however opportunities to do things they enjoyed were often limited by lack of staff time. Visits from relatives and friends were encouraged ensuring that service users kept in touch with people who were important to them. Service users said the food was good and they were offered choice, special dietary needs and preferences were recorded in the individual care plans. Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 13 EVIDENCE: Inspection of care files and care plans demonstrated the wide range of social and educational opportunities that were being pursued by service users. The majority of service users attended day centres or educational placements throughout the week. Several service users had chosen to retire and spend most of their time at home and pursue their hobbies and interests. Transport is provided for service users who require help to attend placements. Service users visit local shops and facilities with a number of them visiting Doncaster in line with their daily living pattern. Some require assistance whilst others are self- sufficient. A number of service users had enjoyed an annual holiday that they had chosen. Some service users discussed the holidays they were planning for later this year. Service users confirmed that staff provided them with choice and all the support that they needed to choose and participate i9n holidays. Family and friends are always welcome as visitors; service users also made visits to the homes of friends and family, there were no visitors on the day of inspection. The meals provided both appeared and smelled appetising. Service users said they enjoyed their meals and that they could always choose other meals if they did not like the meal provided. Staff were observed to encourage and help service users with their meals as needed. Mealtimes were unhurried with extra portions available as required. Service user’s personal dietary likes and dislikes were documented and known by staff. Specialist diets are available for those requiring this service. Staff confirmed that they sought the dietician’s advice as needed by service users. Drinks and snacks were readily available throughout the twenty-four hour period. Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service Users feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 and YA 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a complaints procedure to allow service users to raise any concerns. The staff had been trained in the recognition and reporting of abuse and relevant checks were made prior to them starting work, this reduced the risk of harm to vulnerable service users. EVIDENCE: Service users spoken with were able to describe how they would deal with any issue that made them feel unhappy, and whom they would turn to for help. Staff had received training to enable them recognise any signs of abuse; DMBC has a clear policy for dealing with seen or suspected abuse. Records of in-house complaints that had been received were inspected, there had been five in total, three of which had been substantiated and two substantiated in part. They had been dealt with promptly within the DMBC Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 15 policies and procedures and involved domestic issues. Service users were satisfied with the outcome. Discussions with a new member of staff found that their induction training included information regarding both the complaints policy and the adult protection policy of DMBC; the member of staff was aware of their responsibilities in these areas. Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 and YA 24, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean, tidy and well maintained ensuring that service users live in pleasant and safe surroundings. Access to the second floor was by a flight of stairs, this limited access for service users whose mobility had decreased. The bedrooms were clean and reflected personal choice. Redecoration and refurbishment of the home had improved the service user’s environment. Décor and furnishings in some parts of the home was poor. Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 17 EVIDENCE: DMBC has continued their programme of updating and refurbishing the home. The premises had an overall good standard of décor and furnishings with a number of areas yet to be completed. Provision of new armchairs, TV’s, recarpeting, wallpapering and painting had continued since the last inspection. Service users spoken to whose bedrooms had been redecorated and recarpeted had been offered choice of colours and décor. A number of bedrooms were inspected each reflected the choice and personality of the service user. Access to the second floor is by a flight of stairs this restricted use of this area to mobile service users and visitors only. Communal areas had been re-carpeted, furnished and decorated appropriately. A bathroom had been refurbished and equipped to meet the needs of service users. Toilets and bathrooms had been re-decorated they were readily accessible and provided with aids and adaptations as required. Work was in progress on the day of inspection providing a pathway to provide a separate entrance to the day-care unit to improve the quality of life for service users. This service is neither registered nor inspected by CSCI. Annual servicing of equipment had been planned and undertaken as required i.e. the passenger lift, gas and electrical equipment. Radiators were guarded and window openings restricted to provide a safe environment and reduce risk of injury to service uses. Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 and YA 32, 33, 34, 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Insufficient staff were deployed to meet service user’s needs. Staff had received statutory training to help them meet the needs of service users. Checks had been made on staff to reduce the risks to vulnerable people. EVIDENCE: There is currently one staff vacancy. Staff recruitment had improved since the last inspection. Minimum staff levels were being provided. One waking member of night staff is insufficient to meet the increased needs of service users. Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 19 Service users comments included that staff were good, always helpful, always very busy, and increasingly had less time to assist them to leave the home for outings. The dependency level of the current service user group and their needs has continued to increase; this has placed additional pressures upon staff. Holidays, days out, one to one quality time is seriously restricted. Staff were clearly unhappy and disappointed with this ongoing situation, they were keen to improve the standards of care and service offered. There is no activities person employed, this is a key component of maintaining independence and personal skills. Five members of staff including the manager were spoken to during the course of this inspection, they were observed working with service users, and there was an atmosphere of mutual respect between staff and service users. Three staff files were inspected they met DMBC recruitment policies and procedure requirements. They contained two written references and Criminal Record Bureau (CRB) checks prior to employment of staff to protect vulnerable persons. DMBC provides staff induction, updates and a range of training opportunities. These included fire prevention, moving and handling, health and safety at work, food hygiene, recognition and prevention of abuse and accredited medication training. Staff had achieved their Learning Disability Award (LDAF) before commencing National Vocational training (NVQ). The numbers of staff that had achieved NVQ in care exceeded the minimum level required by the Care Standards Act 2000 and associated regulations. The staff group without exception were well motivated and enthusiastic about their work. They confirmed that not only were they well supported in their work but actively encouraged to develop personally. A new member of staff was available for interview and described his induction, training and developing knowledge of the care needs of the service users. Staff files and discussion confirmed that staff received regular supervision from the manager or his senior officers; this ensures that service users are provided with a high standard of care and service. Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 21 31, 33, 35, 38 and YA 37, 39, 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff felt their managers were supportive and approachable and there was a well-established system of professional supervision. Service users were involved in making decisions about their care and had control over issues that affected their lives. Checks had been made on the major systems in the home such as fire and gas installations to ensure the home was safe for service users. Fire training had been provided for staff to reduce the risk to service users in an emergency. EVIDENCE: The registered manager had recently left his position at Don View, an acting manager Mr M Pass has been appointed until the post is advertised in March. The acting manager is a registered nurse (RNMH), he has a wide range of experience within both the public and private sectors and has achieved the registered managers award and NVQ4. The service users and staff spoken to say the acting manager was approachable, very professional and they felt confident in him. There is no recognised quality assurance system used by DMBC to seek the views of service users and relatives. Regular service user and staff meetings are held; minutes are kept and were available. The responsible individual visits the home on a regular basis, a report is written following the visits. A copy of the responsible individuals monthly report is sent to the local office of the Commission for Social Care Inspection. The manager handles money on behalf of some service users, account sheets were kept, receipts were available for all transactions, and all transactions were witnessed by a second individual. These were sampled by the inspector and were maintained correctly. DMBC auditors audit these accounts annually. All staff had received management supervision at regular monthly intervals; this is required to fully ensure individual staff development and monitoring care practices. Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 22 Staff had received training on moving and handling, fire prevention, food safety and infection control. Records were mainly up to date and well ordered to ensure the best interest of service users. The homes policies and procedures met the required standards. Access for service users to the second floor bedroom area is via a flight of stairs, this presents a hazard to the service users, they were predominantly elderly (two persons under sixty five years) their mobility had decreased with age. No fire exits were obstructed and hazardous substances were securely stored. Statutory servicing and checks of equipment were complete. Don View DS0000031838.V327841.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 Older People 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 2 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 2 34 X 35 3 36 X 37 X 38 3 Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 24 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 OP2 2 OP12 13 Standard Regulation 4 Requirement Each service user must have a written contract /statement and conditions with the home. Service users must be provided with varied opportunities for social and recreational activities both inside and outside the home. The registered person must ensure that the DMBC employs adequate numbers of staff (care staff, activities, housekeeping laundry, and catering staff) to meet service user’s needs. Therefore a full reassessment of service users day and night time needs must be carried out. Staffing levels must be sufficient to meet the identified needs. Suitable safe access must be provided for service users to the second floor. Written confirmation of the action taken should be sent to the local CSCI office by 07/06/07 Effective quality assurance and quality monitoring systems, based on seeking the views of service users must be implemented to measure success DS0000031838.V327841.R01.S.doc Timescale for action 01/03/07 01/04/07 3 OP27 18 01/04/07 4 OP19 13 01/06/07 5 OP33 24 01/04/07 Don View Version 5.2 Page 25 6 OP38 23 in meeting the aims, objectives and statement of purpose of the home. The health, safety and welfare of service users of the second floor must be risk assessed with safe access provided for elderly service users. 01/06/07 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 OP19 Good Practice Recommendations DMBC should review the registered categories for Don View (two service users only were under the age of sixty five years). Don View DS0000031838.V327841.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. Don View DS0000031838.V327841.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!