Inspection on 13/03/08 for Durham Street and Endymion Street

This inspection was carried out on 13th March 2008.

CSCI found this care home to be providing an Adequate service.

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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Durham Street and Endymion Street 03/03/09

Durham Street and Endymion Street 27/03/07

Durham Street and Endymion Street 24/10/06

Durham Street and Endymion Street 03/10/05

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Durham Street and Endymion Street 49 51 & 53 Durham Street Hull East Yorkshire HU8 8RF Lead Inspector Sarah Rodmell Key Unannounced Inspection 13th March 2008 09:00 Durham Street and Endymion Street DS0000065657.V360849.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 Durham Street and Endymion Street DS0000065657.V360849.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. Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Durham Street and Endymion Street Address 49 51 & 53 Durham Street Hull East Yorkshire HU8 8RF 01482 620214 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) cince@avocettrust.co.uk Avocet Trust vacant post Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th March 2007 Brief Description of the Service: The service at 49-53 Durham Street is managed by Avocet Trust who rent the premises from Sanctuary Housing Association. It is one of a small number of similar services that Avocet provides. Avocet Trust is a registered charity. 4953 Durham Street is registered to provide care and accommodation for up to 5 adults with a learning disability. The home in the Holderness Road area, to the east of the city centre. 49-53 Durham Street consists of three separate living units. No. 49 is a ground floor flat for one person, with a bedroom, living room, kitchen, bathroom and rear garden. Nos. 51 and 53 have similar facilities with an additional single bedroom each and are for two adults. No. 51 is at ground floor level. No. 53 is above it, accessed by an internal staircase with own front door. The properties adjoin each other and share a large communal garden at the front. There is parking available on the street. 48 Endymion Street is a terraced property for two people that is owned and managed by Avocet trust. The house consists of a small hall, lounge, dining room, kitchen and utility room, and two bedrooms with en-suite facilities. There are a variety of shops, pubs and health facilities nearby. Public transport to various parts of the city is accessible and in addition, people have access to cars arranged through their mobility benefits. Weekly fees range from £890 £1471 per week. Additional charges are made for the following: newspapers/magazines, hairdressing, chiropody, transport for social activities and sweets. Information on the service is made available to current people via the statement of purpose, service user guide and inspection report. Since the last inspection people have moved from the services at Durham Street to a temporary residence in Sutton, Hull. This is to allow repair work to be completed in the home following flood damage. Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the registration of the home, including information gathered during a visit to the home. Since the last visit the CSCI has received information about the home from the registered provider; there have been no letters or complaints to us from other people. As part of the inspection we send out an Annual Quality Assurance Assessment (AQAA), which is a self-assessment document that the registered person must complete and return to the Commission. It should show how well the home is meeting regulations and National Minimum Standards, what has been done to improve the service since the last inspection or since registration and what still needs to be done. The provider returned the AQAA to us so we had the necessary information to help us check what relatives of people living in the home and professionals working with them think of the service. We sent out surveys to professionals working with people who live in the home and their representatives. Three surveys were returned to us and no concerns were raised with the large majority of responses being positive. The site visit took place on 13 March 2008, beginning at 10.00 am and ending at 4.30 pm. The provider was not told in advance of the date or time we planned to visit. The manager was available for all of this visit and we spoke to the manager and staff during the visit. We looked around the home including people’s rooms and the shared areas of the home, and we inspected records of people’s care, staff files, health and safety documents and other records. What the service does well: People’s needs are assessed before they move into the home, to help make sure that the staff in the home are aware of these and can meet these. People are supported to make decisions in their lives; this includes choices on where to go and what to do. Staff support people to go out in their local community and to maintain important relationships in their lives. Relationships between the people living in the home and the staff team were observed to be appropriate and relaxed. Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 6 There are systems in place to help protect and support people from harm; this includes arrangements for identifying and reporting any allegations of harm and for handling people’s monies. People live in a home that, although is only temporary offers a clean and comfortable environment. In addition, health and safety checks are made to make sure that the home is safe for people to live in. What has improved since the last inspection? What they could do better: People’s assessments, care plans, risk assessments and health records must always be kept up to date and accurate. This will help to make sure that the staff team are aware of the latest needs of this person, how these needs are to be met and how people are to be supported to be safe. People’s health action plans must be developed with other professionals to make sure that people are getting the best support from health and care professionals in the meeting of their health needs. Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 7 Staff must be inducted into the home to nationally recognised standards and receive training specific to the needs of the individual in order for people to receive the best support in the ongoing meeting of their needs. In addition staff need to receive sufficient formal supervision for it to be a useful tool in their personal development and in the ongoing meeting of peoples’ needs. Visits from the registered person or their representative must take place within the requirements of regulation 26. This will provide the management with a regular report on how well the home is meeting the needs of the people who live there and would allow them the opportunity to address any issues. 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. Durham Street and Endymion Street DS0000065657.V360849.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 Durham Street and Endymion Street DS0000065657.V360849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed before they move into the home to help to make sure that these can be met. EVIDENCE: Three files were examined and these all included a copy of the Local Authority Care plan that had been developed from the Local Authority Community Care Assessment. In addition to this there is an Individual Programme Plan (IPP) that has been developed by the home. One relative confirmed in their survey response that they got enough information about the home to help them make decisions. In addition the AQAA recorded that people have transitional stays as part of their move into the home before a decision is made to stay. Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, & 9 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported through a care planning and risk assessment process to live the lives that they choose. EVIDENCE: Of the three files examined, all included a plan of care and an IPP. These documents held information relating to the individual that included a pen picture, their personal history, a weekly activity plan, an assessment of need and support plans. The support plans covered a variety of areas that included self help skills, leisure, relationships, community living and choices. These documents had been dated when they were put in place, for example, 14th March 2007 and it had been identified that they were to reviewed ‘ 6 monthly’. There were copies of annual care reviews held with the Local Authority. Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 11 However only one file held documents relating to a 6 month review held within the organisation. Regular reviewing of these plans, with records kept to show this would help the staff in the home to make sure that they were fully aware of any ongoing and changing needs of the individuals concerned. People’s files included details of the choices that they like to make in their everyday lives, including how they like to take their bath and the leisure activities that they enjoy. People’s daily diary notes included reference to people choosing when to go out and when to spend time in their room alone. People were observed to be given choices including what to eat and drink. When we spoke to staff they told us that people are asked about things and that staff work at the individual’s pace allowing them time to make decisions, and making sure that people are aware of the choices that they can make. Someone who had previously lived in the home required limitations in their lives and it was required that these were agreed through a multi agency approach. The manager told us that this had been completed, although this person no longer lives in the home. People’s files included copies of risk assessments that identified the risks to the individual and others in their daily lives, for example the risk of falling when getting onto a bus. The risk assessments covered a large amount of areas but did not always have the dates that they were started or dates showing that they had been reviewed and were still suitable to the individuals needs. This would help provide information to the staff team to help them make sure that they are continuing to meet peoples’ needs whilst reducing possible risks. Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported to undertake activities that are on the whole their choice, and are supported to maintain relationships and have their dietary needs met. EVIDENCE: People’s files included a weekly activity sheet that showed that a variety of activities within their own home and the community were planned. Their diary notes included that they had been out and about to local shops and cafes. However, not all of the identified activities in their weekly planner were now being completed. The manager explained that due to the recent move of house people are now further away from some activities and that this makes it more difficult to attend. However people are still supported to complete activities in their local community and have accessed some new local shops and facilities; Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 13 the old activities have only stopped during the time of the temporary house move. People’s files included information about people who are important to the individual. When we spoke to staff they had good knowledge of the important relationships in peoples’ lives including both relatives and friends. One person’s diary notes recorded information about how they are supported to maintain contact with a friend and visit them. People were observed to be able to choose where they wanted to be within their home or garden, alone or with other people; people were also asked before someone entered their bedroom. Staff and the people who live in the home were seen to interact positively with each other, reflecting good relationships. There is normally a 4 weekly ‘healthy eating’ menu in place within the home. However the manager and the staff told us that this has not been used whilst people are living in the temporary accommodation. It is recommended that this menu is used to help people maintain their health. One person was seen to be able to have choices over their food and when asked confirmed to us that they liked the food provided. Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported to meet their personal care health and medication needs. EVIDENCE: People now have individual ‘Health’ files. These files include the details of any health needs of the person, how these are to be met, what is good practice and what is poor practice. There are letters and documents from other health and social care professionals held within these files and details of any appointments including the outcomes. However these documents are not consistently completed as they lacked dates of completion or review. One persons weight chart had not been updated and another person’s section labelled’ people who help with my health are’ was blank. This was despite the person having identified health needs that are met through the support of others. If files are not kept up to date it may be difficult for staff to access the correct information to make sure that they are offering the individual the correct support to meet their needs or delays may occur. We received a notification from the home that informed us that one person had a health issue Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 15 that required hospital treatment; we noted that this was dealt with appropriately. It is good practice to develop Health files with a representative from the Health Authority such as a specialist community nurse; there was no evidence that this had been completed. People are supported with aids to living. For example there is a ramp in place to enable safe access to the property and one person has ‘rented’ a wheelchair whilst theirs is broken. Medication is stored in a locked cupboard and up to date records are kept of all medication administration and disposal. A list of staff signatures is kept to easily identify the person responsible for the administration of medication at any given time. Staff files included copies of certificates to show that they had undertaken training with this and staff also told us that they had completed this training. A competency checklist is also in place to make sure that following training staff remain competent in the administration and handling of medicines. However, no evidence was seen that the competency of staff has been checked. Stock sheets are kept to help to ensure that there are adequate quantities of medicines in the home. A minor discrepancy was found with the stock of medication. However the manager told us that this was due to discrepancies in the amount of medication being provided by the pharmacist and that this is something that is being dealt with. Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported by policies and procedures to be protected from harm and to raise concerns. EVIDENCE: There is a complaints policy held within the home and the manager told us that no complaints had recently been made to the home. Of the three surveys received one person commented that they were not sure how to make a complaint should they need to and it is recommended that work is undertaken to make sure that everyone is aware of the policies and procedures. Staff have access to a copy of the Local Authority policy, ‘ The Protection of Vulnerable Adults’ (POVA) and have accessed training. Staff talked to us about protecting people; they have a good knowledge of POVA and the actions that they would take should they suspect an incident of harm had occurred. One safeguarding issue within the home has been dealt with appropriately, with the home and other agencies working together to achieve this. People are supported by the staff in the home to manage their personal finances. Records are kept of all purchases and receipts to show the costs and items purchased. Durham Street and Endymion Street DS0000065657.V360849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a clean warm and comfortable home. EVIDENCE: The property in Durham Street was damaged by the floods last year and work has recently begun to repair it. Due to this the people living in Durham Street have temporarily moved to another home owned by the organisation. When we visited this home it was warm and comfortable, with one person who was at home told us that they liked the temporary home. Staff have helped people to unpack their belongings and to settle into the home, whilst respecting their wishes - one person has requested not to unpack, as they know it is only a temporary stay. At a previous visit it was noted that staff that provided sleep-in support for the people living the home did this by sleeping on a camp bed in the lounge. The Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 18 manager has since met with the staff team and it was agreed that a new bed would be purchased for sleep-in staff to use. No concerns have been raised regarding this issue since the last visit. However, this situation remains unsatisfactory; staff must be provided with adequate sleep-in arrangements that do not intrude on the communal areas of people living in the home. Endymion Street is an older property that has been refurbished and updated. It provides clean and comfortable accommodation to the people who live there, and people have personalised their rooms. The staff told us that they are continuing to help people to furnish their home with smaller items to make it their own. Records were in place for the checking of fire equipment and alarms and these were found to be up to date. In addition to this a member of staff told us that they continue to complete these checks. Durham Street and Endymion Street DS0000065657.V360849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are supported by a staff team that are trained and supervised in their roles, although the lack of regular formal supervision may alter the effectiveness of this. EVIDENCE: Staff recruitment files were not available as they are held centrally within the organisation. Another inspector has inspected these separately and no issues or concerns were found. Of the three staff files reviewed two had an induction portfolio that showed that they had covered the organisations own induction. However, no evidence was available that this induction meets the requirements of ‘Skills for Care’ and the manager told us that this is something that is being addressed centrally. Peoples’ files included certificates of training - examples of these were Health and Safety, Fire, Moving and Handling and Medication. One person had a certificate that confirmed that they had completed Fire Training Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 20 in November 2008 and the manager is to address this error. The manager has developed a staff training programme which includes the details of all qualifications held by staff and when this is next due for renewal. He told us that this plan is forwarded to the central office for action. One relative confirmed to us in their survey that they felt people had the right skills and experience to look after people properly. Staff have supervision files and records in place. The records show that supervision covers different areas of their job as well as their own development. Only one person had a record to show that they had received supervision this year, with other people’s last supervision being in November 2007. This means that the requirement that people receive a minimum of 6 supervision sessions a year is not met. However, in discussion, staff told us that they felt well supported and that the manager was readily available. Durham Street and Endymion Street DS0000065657.V360849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported by an experienced manager, who assists them to be involved in the development of the home, and where systems are in place to maintain their health and safety. EVIDENCE: The manager confirmed to us that he has undertaken one training course over the last year to update his skills in relation to The Protection of Vulnerable Adults (POVA). He is not registered as a manager with the CSCI and no application for registration has been received by the CSCI. Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 22 There is a quality assurance system within the home and last year surveys were sent out as part of the quality assurance procedure. They were sent to staff and some of the people living in the home but other professionals were not included. The quality assurance system could be developed further to include the opinions of other stakeholders. The manager told us that no surveys have been sent out this year but that it is planned to complete this once the service has moved back to Durham Street. Regulation 26 reports are received for this service, although these were completed in April, May and December and not on a monthly basis as is the requirement. These reports show that the management of the home are assessing how well the home is operating and meeting people’s needs. The manager told us that a staff meeting had taken place last week and the minutes of these showed that it covered organisational and individual house issues. There is a Health and Safety file that includes a copy of the Health and Safety policy and risk assessment. There are additional risk assessments relating to the use of the Barbeque, the risk of falls, hot water, fire and cleaning materials. An Electrical wiring and gas safety certificates are available for the home to show that these areas are safe and do not pose a risk to the people living and working in the home. Durham Street and Endymion Street DS0000065657.V360849.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 X 34 X 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 3 x 2 X 2 X X 3 X Durham Street and Endymion Street DS0000065657.V360849.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 Standard YA6 Regulation 14 (2) Requirement The registered person must make sure that individual assessments and care plans are regularly reviewed and kept up to date. The registered person must make sure through a review process that individual risk assessments are kept up to date and that people are protected from unnecessary risks of harm. The registered person must ensure that health action plans are prepared and implemented for all people in partnership with the health authority. (Timescale of 31/01/07 and 30/06/07 not met) The registered person must make sure that in order to help to meet the health needs of the individual; records relating to health conditions and the support provided are kept up to date and correct. The registered person must ensure that all new staff receive both in house induction and induction training that meets LDAF standards. DS0000065657.V360849.R01.S.doc Timescale for action 13/04/08 2 YA9 13, 15 13/04/08 3 YA19 13 (1) 30/04/08 4 YA19 17 (1) & Schedule 3 30/04/08 5 YA32 18 (1) 30/04/08 Durham Street and Endymion Street Version 5.2 Page 25 6 YA35 18 (1) 7 YA36 18 (2) 8 YA37 9 YA37 YA39 Care Standards Act 2000 26 10 YA39 24 (Timescale of 03/10/05,31/01/07 and 30/06/07 not met) The registered person must ensure that service specific training is provided that enables staff to meet the assessed needs of people. Previous requirement of 30/06/07 not met. The registered person must ensure that all staff receives formal supervision at least 6 times per year. (Timescale of 03/10/05, 31/03/07 and 30/06/07 not met) The registered person must make sure that the manager of the home applies to become registered with the CSCI. The registered person must make sure that the quality visits as per the requirements of Regulation 26 are undertaken on a monthly basis. The registered person must further implement the quality assurance system into the home to takes into account the views of people in the home and stakeholders. (Previous Timescale of 30/06/07 not met). 30/06/08 30/04/08 30/04/08 30/04/08 30/06/08 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 2 Refer to Standard YA17 YA22 Good Practice Recommendations The healthy eating menu plan should be used to help meet individual dietary requirements. The registered person should make sure that everyone involved with the home is aware of the complaints system. DS0000065657.V360849.R01.S.doc Version 5.2 Page 26 Durham Street and Endymion Street 3 4 YA28 YA35 The staff sleep in area should not intrude on peoples’ communal areas within the home. The registered person should make sure that all staff training certificates are correctly dated. Durham Street and Endymion Street DS0000065657.V360849.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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