CARE HOME ADULTS 18-65
Donna Claire Venture Short Break Service Donna Claire House 6 Seaburn Terrace Seaburn Sunderland SR6 2BZ Lead Inspector
Mrs Elsie Allnutt Key Unannounced Inspection 8th August 2006 10:00 Donna Claire Venture Short Break Service DS0000015747.V304185.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 Donna Claire Venture Short Break Service DS0000015747.V304185.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. Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Donna Claire Venture Short Break Service Address Donna Claire House 6 Seaburn Terrace Seaburn Sunderland SR6 2BZ 0191 529 3171 NO FAX 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) Miss Geraldine Plunkett Care Home 6 Category(ies) of Physical disability (6) registration, with number of places Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th February 2006 Brief Description of the Service: Donna Claire Venture is a short break service operated privately by two people, Geraldine Plunkett and Audrey Turnbull. The service provides planned breaks for both men and women with physical disabilities, between the ages of 18 and 65 years, and who are dependent upon carers for care and support. The level of service provided depends on the needs of the individual. Donna Claire is situated close to the sea front and within easy reach of a range of shops and other services. The house is a large 2 storey detached building with a bungalow annexe within an area of private housing in Seaburn. It has space and facilities to accommodate people who use wheelchairs and provides 4 single bedrooms and 1 double, now used as a single. There are adaptations and equipment to meet the needs of people with physical disabilities. The aim of the service is to deliver a service as near to a holiday experience as possible, as well as providing a respite period to their carers. During their stay people are supported, by staff to take part in community based activities. A garden and patio is also available for the people using the service. The home has developed a Service User Guide that informs prospective service users about the service, the aims and how these are met and a copy of the recent inspection report is available in the home for anyone to read. The fees charged by the home are £870:00p per week. Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took 6:00 hours over one day in August 2006. The people who use this service prefer to be referred to as guests rather than service users. This will be respected throughout this report. The views of five guests and six members of staff were sought on the day. As not all of the guests have verbal communication their satisfaction of the service was interpreted not only through speech but the observations of body language, interaction with staff, discussions with staff and the examination of records. This process demonstrated that all were satisfied with the service and the care and support given by staff. Several guests were able to give an explicit account of their life while staying at Donna Claire and one guest commented, “This is my holiday and I’ve been coming for many years, I love it” another commented “The staff are very nice, this is my first time here and I think I’m going to like it.” As part of the inspection process the service users’ care files, a sample of the homes records and areas of the building were examined. What the service does well:
The standard of accommodation provided by this service is good. It is well maintained and as a result of effective cleaning routines offers a clean and hygienic environment. The inside walls of the home are decorated with attractive paintings and craftwork, which have been skilfully produced by people who have used the service and friends of the home. These offer an added attraction for people staying at the home, while promoting the skill and abilities of the creators of the work. The gardens that surround the building are well stocked and maintained and provide attractive areas for guests to look on to or relax in. The manager stated that guests and people passing often comment favourably about the abundance of colour in the summer. The walls surrounding the garden currently display a variety of summer flowers. The friendly interaction of guests and staff create a warm and welcoming atmosphere in the home. One member of staff commented, “We aim to make each guest’s stay as enjoyable as possible.” The staffing ratio at this service is excellent and as a result guests receive a service that meets their aspirations and personal needs. Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 6 The kitchen/dining area includes a dining table that accommodates both guests and staff together providing a focus where a mixture of serious discussion and light “chatter” combined with positive humour takes place. Here guests are given the appropriate amount of time and support to take part in discussions about the service delivery and any planned activity. It is an area where the rights and equality of the service users are positively promoted. The manager and staff ensure that full information in relation to guests’ care needs is received from the guests, their main carers and other professionals involved in their care, prior to their stay. This ensures that the appropriate resources can be put in place prior to their arrival and the needs of guests are fully addressed in the way that they prefer and are used to. One guest commented, “When I arrived my room was set up the way it is at home.” During discussions with the manager and staff it was established that good relationships have developed between Donna Claire and community health services. Nurse Specialists for example in relation to Parkinson’s and Huntington’s disease have delivered talks to staff about the diseases and have equipped staff with important knowledge and advice which guide them in appropriate care practices that benefit guests. What has improved since the last inspection?
So that clinical procedures continue to be carried out in a professional way and guests receive the relevant sort of care, some staff have up dated their training and knowledge regarding PEG (Percutaneous Endoscopic Gastrostomy) feeding. A Specialist Nurse delivered this training. To ensure that guests are protected and any allegations of abuse are taken seriously and promptly, all staff have now received training related to the Local Authority’s Protection of Vulnerable Adults (POVA) Procedures and are now aware of the procedures to follow. There have been marked improvements in staff training overall. So that all staff received training related to their roles within their work time, the manager closed the service for one week while different training sessions were provided. This covered all mandatory training. The percentage of staff now qualified in NVQ has reached the required percentage of 50 . This means that trained and qualified staff now supports guests. The manager and assistant manager have now organised planned formal supervision and appraisal sessions with staff. This provides private time for individual staff to be supported and guided in good care practices, training needs and to address possible deficiencies in their performance. This will help to ensure that guests always receive good standards of care Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 7 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. Donna Claire Venture Short Break Service DS0000015747.V304185.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 Donna Claire Venture Short Break Service DS0000015747.V304185.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): 2,4,5 Quality in this outcome area is good. This judgement has been from evidence gathered both during and before the visit to the service. The needs of guests are adequately assessed prior to using the service so that the service can confirm to guests that they can meet their needs. So that this is confirmed in writing the service must give each guest a written contract stating the service’s terms and conditions, as well as including the full cost of the stay. EVIDENCE: All of the people that use this service for holiday and respite reasons chose to do so. All are physically disabled and live at home with a carer, some nearby but many from outside the area. The manager stated that as much information about a new guest is sought from the service user, the referring agency and the family/main carer, prior to their stay. One of the guests currently staying at the service, with complex needs, confirmed that they had made a visit to Donna Claire prior to making their decision to stay for a week. Records also confirmed that the guest and other people involved in their care, provided information about their care and social needs. Records available included; a preadmission assessment and care plan from the Care Manager, an assessment of the person’s needs and that of the home’s environment by an Occupational Therapist, and the home’s own assessment and care plan.
Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 10 Another guest confirmed that their aspirations made known prior to staying were always met. A trip on a steam train had been organised during their stay to address their interest in trains and railways. The home has a contract in place relating to the terms and conditions of guests’ stay at Donna Claire. However, although contracts from the referring agency with details of the cost of their stay and how these are to be paid were available, contracts from Donna Claire stating their terms and conditions were not. This was discussed with the manager who agreed that from now, new guests would receive a contract from the service stating the terms and conditions of individual guests stay. Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been from evidence gathered both during and before the visit to the service. Each guest has a care plan that; is easy to understand, considers all areas of their lives, demonstrates how decisions are made and includes risk assessments. EVIDENCE: A care plan is in place for each guest that includes explicit details of the guest’s care and social needs. They also include information about individual likes and dislikes and the preferred way individual guests prefer the room organised. Although this is usually determined by their physical needs, for example the position of the bed and easy chair, preference to whether an individual might prefer a television or radio in their room is also recorded. So that the care delivered by individual carers is consistent, the care plans include guidelines for staff to follow, for example a care plan is in place regarding one guests mobility needs when transferring from wheelchair to bed. The guidelines clearly describe; how this is done, the actions to be taken by the carer, what and how equipment is used and how much of the task the
Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 12 guest carries out independently. It is evident that the emphasis is on the safety and comfort of the guest and the maintaining of their independence. Risk assessments and plans how the risk is safely managed, are also in place for example, regarding the moving and handling of one guest and their use of a recliner bed and chair. One guest was observed using a wheelchair without footplates, when discussed with the guest although they were aware of the risks related to this it was established that this was their decision. The risks involved in this were discussed with the manager who agreed to discuss this further with the guest and to put a risk management plan in place in relation to it. Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 13 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): 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to the service. Although the people who use this service often have complex needs, their right to choice and to live a normal and as active life as possible while staying at Donna Claire Venture, is successfully promoted and fully supported. EVIDENCE: By observing life in the home it was evident that guests are supported to live a full and active lifestyle. Staff work in a lively way with respect and skill and involve guests in making their own choices about what they prefer to do. On arrival at the home one guest was still enjoying a full cooked breakfast while other guests were being supported by staff to get ready for their day’s activities. As this was happening the order of the day was being discussed. Positive and respectful interaction was observed between staff and guests with conversation being directed openly towards the guests. Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 14 Guests enthusiastically discussed the varied activities they enjoy while staying at the service and how they are supported to take part in them. One guest said, “I like coming here because I like to go bowling.” Another said “ I love coming here there’s always plenty to do and the staff are very good.” Another guest confirmed that it was just like home from home and said, “I even get my Scottish local paper ordered for me.” Another guest explained how the activities they wanted to do during their stay were discussed prior to their stay and records confirmed this process. Guests explained that this was their shopping day and this took place in small groups two going to Newcastle and another two going to Sunderland while one chose to stay local and have a walk along the seafront. One guest demonstrated their delight and excitement about going out through body language and facial expressions Another guest confirmed the plans to take a trip on a steam train the following day. Although breaks at this service are seen as a holiday for the guest it is also a respite period for families and carers. It is not often therefore that maintaining family contact would be part of the service, however for one guest who lives in Scotland and who has a sister who lives locally, arrangements are made by the service for them both to meet at Donna Claire. Guests confirmed that the food served at Donna Claire is always very good, plentiful and very tasty. The manager confirmed that guests’ preferences are taken into consideration and this often determines changes to the planned menu. Records confirmed this. Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 15 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): 18,19,20 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Service users receive personal support appropriate to their needs and preferences and in a way that enables their privacy and dignity to be respected. EVIDENCE: The people using the service are temporarily registered with a local GP and District Nurse during their stay at Donna Claire who are called upon if and when needed. The service supports service users to hospital appointments during their stay, only as a special request and if the home is confident that they have all the necessary information. Close communication is kept with the families in relation to health issues of the individual, as well as with the Social Worker and the Community Nurse. When there are concerns all parties are informed. Staff were observed taking care to explain to guests how they are to be assisted with personal tasks, making sure that it is the individual’s preferred way. Service users confirmed that they direct their terms of personal care. They also confirmed that their dignity and privacy is always respected and care is
Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 16 taken to ensure that their personal image is considered also and assistance is given to dress with the person’s choice of clothing and style. The observation of the interaction of staff and service users confirmed this. The manager stated that so service users’ independence is promoted and the care is consistent with that received at home, personal aids such as electric mattresses, electronic communication aids and electric wheelchairs are often brought to the service with them. A guest confirmed that they had brought their personal slings for the hoist and bath cradle so that their comfort and care needs would be consistent to that received at home. The care plan included guidelines for staff to follow in relation to the use of this equipment. One guest was observed independently moving around the house in a wheelchair and accessing their room by using the lift. Observations also confirmed that the service supplies equipment and appliances if needed, for an example there is a high/low electric bed with integral bed sides if needed. Some people using the service need to receive their food and medication administered through a PEG (Percutaneous Endoscopic Gastrostomy) tube. Records prove that there are written guidelines given by a healthcare professional for staff to follow in relation to this procedure. The manager and staff confirmed that staff are trained in this procedure and the training is currently being updated. Records confirmed that medication is administered appropriately and all but 2 staff have attended training in relation to this. The manager was advised that any staff who administers medication must have attended appropriate training. The manager agreed that only those trained administer medication and it is hoped that this will include all staff in the near future. Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Arrangements are in place to help protect guests from abuse and to seriously address complaints and concerns about the service. EVIDENCE: Guests confirmed that they know how to complain and they felt that their concerns were listened to and addressed appropriately. A copy of the complaints procedure is available in the home. The manager explained that discussions take place with each guest prior to them leaving to make sure that everything during their stay has been to their satisfaction and whether anything could have been better. The results of such conversations are recorded in individual care files and any issues raised, are addressed prior to the next visit. The home follows the Adult Protection Procedures set by the Local Authority. The manager and staff confirmed that they have received training related to these. In addition to this the manager and staff confirmed that in house training has taken place in relation to protection issues and the manager regularly addresses issues in relation to good, respectful care practice, by raising staffs’ awareness of what is acceptable and what is unacceptable care practice. All of the guests’ spoken to, at this and previous inspections, confirmed that they are treat with respect at all times. Observations confirmed this. Donna Claire Venture Short Break Service DS0000015747.V304185.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. As a result of effective maintenance and refurbishing programmes, and good cleaning schedules the standard of the environment is good, providing service users with an attractive and homely place to stay. EVIDENCE: The environment, which was clean and tidy, maintains the same high standards as found at previous inspections. All areas of the building are nicely decorated and furnished to a good standard. New curtains have been purchased for the lounge that are of good quality, coordinate with the other furnishings and are fire retardant. This is an attractive area for guests to relax in with views of the sea and gardens or to watch TV. Four electric recliner chairs are available in the lounge, all offering different aids to address different mobility needs. The house is accessible for people who rely on wheelchairs for mobility. One guest was observed moving around independently in an electric wheelchair easily managing doorways and the passenger lift to access their room on the first floor.
Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 19 The gardens that are attractive are also easily accessible out of the main door. The bathroom facilities where a specialised bath and separate shower facility address the varied needs of the guests remain satisfactory. The manager shared her plans at a previous inspection to refurbish the ground floor toilet with new facilities in the near future. The previous recommendations to replace the window with obscure glass at the same time remains. The home has carried out risk assessments for each person who uses the service in relation to having unguarded radiators and in the event of a risk being identified the radiator(s) in question are covered with soft protection. This was evident during the inspection. However it remains a recommendation of this report that radiator covers should be fitted to all radiators. Donna Claire Venture Short Break Service DS0000015747.V304185.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34,35,36 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Good staffing ratios, appropriate training opportunities and supervision, ensures that service users are appropriately supported and protected by a competent and qualified staff team. However recruitment procedures could protect guests further by standardised application forms being put in use. EVIDENCE: There were five guests using this service at the time of the inspection, all with high needs and five members of staff were on duty to support them. This meant that guests’ individual needs were appropriately addressed and they were able to take part in the activities of their choice with direct support at all times. The staff team is made up of staff, some who have worked at the home for many years and all who, the manager stated, are committed to their role. Staff discussed the needs of the guests with respect and understanding. When observing staffs’ social interaction with guests, their response, and the way they addressed guests’ needs, it was evident that positive relationships develop. Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 21 Due to consistently maintaining the high level of staff on duty, this service has found it difficult in the past, to offer the amount of training needed to maintain a fully trained workforce and to meet the necessary training targets. So that staff could up date individual training needs and acquire new knowledge and skills appropriate to guests needs, the manager discussed how the service closed for one week, during which time training opportunities were provided by relevant training agencies. Records and staff confirmed this. Over 50 of staff are now qualified in NVQ and all but 2 are up to date with mandatory training. There are plans to address this with the remaining staff over the next few weeks. The examination of staff records confirmed that guests are protected by good recruitment procedures. Two references and CRB checks were in place for recently recruited staff. Currently it is practice at this service for applicants to forward a personal CV or letter of application when applying for work. So that the service has consistent personal information about staff, their work history and qualifications, the manager was advised of the advantages of having a standard application form for prospective staff to complete. Although the manager in the past has always supervised staff directly while working with them, difficulty has arisen when trying to find time to organise planned formal supervision and appraisal sessions. The registered manager, with the support of the assistant manager, has now addressed this and planned supervision sessions are now taking place. Donna Claire Venture Short Break Service DS0000015747.V304185.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The manager, who is well supported by the staff team, provides a service that is well run, safe, and focussed on the best interests of the service users. EVIDENCE: This home is well run by a manager that is competent and consistent in her role. The manager has a teaching qualification, managed the home for fourteen years and has a wealth of experience shared with her business partner, who for many years prior to retirement was a qualified nurse. She has recently updated her mandatory training. The manager has decided to register to complete the Registered Managers Award (RMA) and she is currently applying for funding to do this. The assistant manager who supports the manager in the running of the service is planned to complete the RMA and NVQ4 in Care by December 2006. Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 23 The fire records and accident book were satisfactory. The issue related to the radiators without covers remains an issue and a recommendation of this report. So that staff are aware of the health and safety policy of the home, staff confirmed that they are given a copy of the document with their work contract. An inspection was carried out by the fire service in May 2006 and it was recommended that fire detectors connected to the fire alarm system be fitted in the lift and electricity cupboard. Although fire detectors have been fitted into these areas they are not connected to the alarm system. The manager confirmed that this would be addressed. Discussions relating to; whether the alarm system should also be extended to the loft that is used for storage purposes and the fact that the doors in the house do not have intumescent strips fitted, took place. The manager agreed to take advice from the Fire Service on these issues and to follow their recommendations. Donna Claire Venture Short Break Service DS0000015747.V304185.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 3 5 2 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 3 X X 2 X Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 25 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA5 Regulation 5(1)(b) Timescale for action Guests staying at the home must 30/09/06 agree with and receive a contract from the home stating the terms and conditions of their stay in addition to that received from the referring agency. A risk assessment/management 31/08/06 plan must be put in place regarding guests, without or refusing to use, footplates on their wheelchairs. The training received by staff in 31/10/06 relation to the procedures carried out when supporting service users to feed via PEG (Percutaneous Endoscopic Gastrostomy) feeding must be monitored and reviewed. (Timescale of 31/03/06 not fully met.) The registered manager must 31/10/06 ensure that all staff who administer medication receive training in relation to the Safe Administration of Medication. The registered manager must 30/09/06 keep information about all staff employed at the home as listed in Schedule 4 of the Care Homes Regulations 2001 including their
DS0000015747.V304185.R01.S.doc Version 5.2 Page 26 Requirement 2 YA9 13(4)(c) 3 YA18 18(1)(c )(i) 4 YA20 13(2) 5 YA34 17(2) Donna Claire Venture Short Break Service 6. YA37 9(2)(i) 7 YA42 23(4) name, address, date of birth qualifications and experience. So that the manager gains the 31/10/06 recognised qualification she must register for the Registered Managers Award and NVQ 4 in Care or another relevant qualification. (Timescale of 30/04/06 not met) The registered manager must 31/08/06 address the recommendations made by the Fire Service regarding fitting fire detectors connected to the fire alarm system in the lift and electricity cupboards. The registered manager must also seek advice from the Fire Service regarding; the necessity of extending this system to the loft areas, and the issue that the doors in the house are not fitted with intumescent strips. 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 YA42 3. YA27 Good Practice Recommendations The manager should ensure the safety of the service users by ensuring a low surface temperature on radiators, for example through the use of radiator guards. The plans to refurbish the toilet on the ground floor with facilities appropriate to the needs of people with disabilities should go ahead, while at the same time it is recommended that consideration is given to replacing the windows with obscured glass. The registered manager should provide a standard application form to applicants, to inform the service about their work history, work experience, qualifications and fitness to carry out the job.
DS0000015747.V304185.R01.S.doc Version 5.2 Page 27 5 YA34 Donna Claire Venture Short Break Service Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Donna Claire Venture Short Break Service DS0000015747.V304185.R01.S.doc Version 5.2 Page 28 - 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!
