Inspection on 15/02/08 for Elsdon Mews (26)

This inspection was carried out on 15th February 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elsdon Mews (26) 16/02/09

Elsdon Mews (26) 16/02/07

Elsdon Mews (26) 21/06/05

Elsdon Mews (26) 09/03/05

Elsdon Mews (26) 07/09/04

Elsdon Mews (26) 16/03/04

Similar services:

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Dilston College Of Further Education

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Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Elsdon Mews (26) Hebburn Tyne And Wear NE31 1RE Lead Inspector Miss Nic Shaw Key Unannounced Inspection 15th February 2008 09:30 Elsdon Mews (26) DS0000000256.V356939.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 Elsdon Mews (26) DS0000000256.V356939.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. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elsdon Mews (26) Address Hebburn Tyne And Wear NE31 1RE 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) 0191 483 3936 0191 483 9747 Northumberland, Tyne & Wear NHS Trust Jackie Mills (not yet registered). Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Learning disability - Code LD, maximum number of places: 8 The maximum number of service users who can be accommodated is: 8 16th February 2007 Date of last inspection Brief Description of the Service: 26 Elsdon Mews provides ordinary housing for people with learning disabilities, many of who were formally resident in long stay hospitals. Elsdon Mews can provide personal care for 8 people. The service cannot provide nursing care. The home is a purpose built bungalow and due to its design and layout it blends in well with other properties in the community. The house has two dining room/lounges, a kitchen/dining area, and eight single bedrooms. There is a garden at the back of the home which service users can use safely. The home has wide passageways and is suitable for people who use wheelchairs. There are separate laundry and storage facilities. The home is situated close to the town centres of Hebburn and Jarrow and within close proximity to a range of local amenities and facilities. There are bus stops nearby which link with the main regional centres and the home has its own transport. The weekly fees payable are £980.91 Elsdon Mews (26) DS0000000256.V356939.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 1 star. This means that the people who use this service experience adequate quality outcomes. Before the visit: We looked at: • information we have received since the last full visit on 15th February 2008. • how the service has dealt with any complaints & concerns since the last visit • any changes to how the home is run • the provider’s view of how well they care for people The Visit: An unannounced visit was made on 15th February 2008. Due to the complex communication needs of the service users who live here it is not possible to find out their views by talking with them. Therefore: During the visit we: • observed how staff interacted and supported the people who live here • talked with staff &the deputy manager • looked at information about the people who use the service and how well their needs are met • looked at other records which must be kept • checked that staff had the knowledge, skills and training to meet the needs of the people they care for • looked around parts of the building to make sure it was clean, safe and comfortable • checked what improvements had been made since the last visit We told the deputy manager what we found at the end of the visit. What the service does well: There are good admissions procedures in place. This means that if ever there is a vacancy in the home, only those people whose needs can be fully met by the staff would be admitted. Service users are helped by staff to keep in touch with their families and friends. Staff help service users with their personal care in a way that they prefer and make sure that they regularly receive health care checks. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 6 There is a good complaints procedure so service users and their families know that their views will be listened to and acted upon. The staff clearly understand each service user, how they communicate and how best to meet their needs. The staff said that the new manager was very good and in the short time she has been at Elsdon Mews things have “started to improve”. What has improved since the last inspection? What they could do better: There needs to be more detailed records kept of menus. This is to make sure that service users are provided with a varied, nutritious diet. It would also be good if menus were available with pictures to help people choose what they want to eat. Some of the staff need training in the Local Authority safeguarding adults procedures so that they know what to do should they witness or suspect abuse. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 7 There are too many people with high care needs living in this environment and this needs looking at. The manager needs to develop a training plan so that she can make sure that everyone gets the training they need. She also must tell us when there has been a serious incident in the home, such as the boiler breaking down, as this is a legal requirement. The manager must carry out more checks to make sure the service users are getting a good service. She also needs to carry out her plans to make sure everyone gets regular fire instructions and drills. The manager must make sure that the home is safe for everyone living and working here by carrying out what are called “risk assessments”. This means looking at what may be dangerous to people and finding ways of making it safe. Where risk assessments have been written these must be regularly reviewed. This is so that staff know whether or not the action plan they put in place to reduce the risk is working. 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. Elsdon Mews (26) DS0000000256.V356939.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 Elsdon Mews (26) DS0000000256.V356939.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): 1, 2 and 4. Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. Good information enables potential service users to make an informed choice about where to live. Good assessment processes also ensure that potential service users needs will be met. EVIDENCE: There is a Statement of Purpose and a Service User Guide which set out the aims and objectives of the home. These documents have been reviewed and amended to provide up-to-date information about the service. They are written in plain English and pictures and symbols are used to help people understand them. Although there have been no new admissions to the service since the home first opened some years ago, there is a clear admission policy and procedure in place. This includes obtaining an up-to-date care management assessment as well as offering trial visits. A copy of the contract is available in the home for those people chosen to case track. The manager is in the process of sending a copy of this to the service users’ relatives to sign to show that they had read and understood the terms and conditions of residency. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. The care plans have improved and give specific information about service users as individuals, which helps to provide a good quality of care. Staff have begun to look at ways of helping service users to take risks and make choices in their daily lives enabling them to lead independent lifestyles. EVIDENCE: The majority of care plans viewed provide staff with clear detailed guidance on the action they need to take to meet each service user’s assessed personal and health care needs. They are written in plain English with symbols and pictures to help people understand them. They are all different and provide good information about all areas of the individual’s life as well as information about their likes, dislikes, goals and aspirations. The manager is currently arranging for review meetings to take place. service users’ advocates have been invited to attend these. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 The Page 11 There is also good information about those situations which cause people to become agitated and what staff should do to support them when this happens. Staff know and record, in the communication passports, the preferred communication style of each individual. For example, in one plan it was clearly recorded that the service user is able to understand and make choices if they are shown objects. In another person’s plan their goal is to be able to use simple Makaton signs. Everyone has a person centred plan. These have been developed with the involvement of the service user, their care manager, advocate, manager, support staff and two facilitators. They provide good information about “what’s not working” for the service user, examples of what would be a “good day” for each individual as well as an action plan. Each service user has a copy of their person centred plan in their bedroom. Records showed that the management of risk is beginning to focus upon improving outcomes for service users, particularly in relation to living an independent lifestyle, rather than keeping people safe. For one service user this has meant that they are now able to enjoy using the kitchen, when two staff are present. Person centred plans also contain a “keeping safe” section in which risks are identified together with details of any steps which need to be introduced to minimise the risk. One care plan viewed did not contain as much detail as the others. The deputy manager said that not all have been reviewed and up-dated, however, confirmed that work is continuing in this area. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. Opportunities for service users to lead active fulfilled lifestyles and be valued members of the community have improved, with their rights as individuals being respected. It was not possible to determine form records whether service users are offered a varied menu with wholesome food that would promote their health and well-being. EVIDENCE: As previously mentioned risk assessments are being developed, the focus being upon service user’s developing independent living skills. Support plans showed how service users are being encouraged in this area. For example: one person is encouraged to take responsibility for their laundry another person is involved in car maintenance and cooking sessions. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 13 A domiciliary care agency now provides additional support with community and leisure activities. This means that there are more opportunities provided for service users to take part in a wider range of activities. Examples of these include bowling and visiting a sensory room. There is also good information in the “things I like” part of the person centred plan about each service user’s choice of activities. For example; one service user likes to groom horses, go swimming, walking and going out for dinner. The record of activities for this person showed that they are regularly supported to enjoy their chosen activities. Staff said that now that there are more staff there are more activities for service users. There is a full time “enabler”. This is a member of staff employed specifically to arrange and support the service users with activities. Staff said that some new activities recently introduced by the enabler have included trampoline sessions and cycling. The manager has negotiated funding for a second full time enabler. Staff support the service users to maintain regular contact with their family and friends by arranging and accompanying them on visits. Staff make sure that relatives are kept up to date with any changes in their family members health care needs. There is a four week menu and although this does not offer service users with a choice of main meal, an alternative is always available. Menus are developed based on the staff’s knowledge of the service users likes and preferences. The menu viewed, however, was not in enough detail to show that service users had been provided with a varied, nutritious diet. For example: “soup and bun”, “pizza/chips and sweet”, “pork chops with veg”. The menu was also not available in alternative formats, such as pictures and symbols, to help people understand what is available. The lunchtime meal was served by staff to service users. Staff sat with the service users during lunch and offered them support where this was needed. The majority of the people who live at Elsdon Mews need support at mealtimes and some have diverse needs in relation to food. In an attempt to make this as a relaxed experience as possible for everyone, the group of eight people are divided into two groups of four. Both groups have their meal at the same time using the two dining areas. On the day of the inspection visit some of the service users had gone out for their lunch. As there were less people to support at this time a more relaxed mealtime experience was created. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. Service users receive the support they need from staff to ensure that their personal and health care needs are met. Service users are generally protected by the homes medication policies, practices and procedures. EVIDENCE: The care plans provide clear guidance to staff on the service users preferences on how their personal care needs are to be met. The areas covered within the care plans include bathing, mobility, getting dressed, drinking and the support each person needs at mealtimes. The care plans are all different and the content reflects the personal care needs of each service user. Service users have regular access to their GP and other medical professionals, such as opticians, dentists, occupational therapists, speech therapists and consultant psychiatrists. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 15 In response to some of the more challenging complex needs of the service users the manager has sought advise and support from a variety of different health care professionals. This has included input from the “Home Assessment Team”, known as “H.A.T”, who provide on-going support to the staff. Medicines are stored safely and securely and systems are in place for ordering and the safe disposal of medication. An audit of the medication held in the home was checked and correct and corresponded to the medication administration record. In one person’s care plan a risk assessment had been completed in relation to medication. This, however, was last reviewed in 2005 and there was no further evidence in the records to show whether the risk reduction strategies in place had actually been working. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. We have made this judgement using a range of evidence, including a visit to this service. Arrangements are in place through the complaints process to promote the service users safety and offer protection. Appropriate policies and procedures are in place which protect service users from abuse. However, some staff need further training to fully safeguard people. EVIDENCE: There is a complaints procedure. This is provided in pictures and symbols to assist those people who have verbal communication difficulties. A copy of the complaints procedure is available in the Service User Guide The complaints record confirmed that there have been no complaints since the last inspection. The home has its own policy and procedure documents relating to abuse which are available to staff to guide them if they have any concerns in this area. There has been one safeguarding adult referral made since the last inspection. This involved an incident between service users and, although managed appropriately by the home, risk assessments had not been up-dated as a result of this. Some of the staff have not received training in the local authority safeguarding adults procedures, (formally known as Protection of Vulnerable Adults (POVA)). Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 17 Service users personal money is stored securely and detailed records of expenditure incurred maintained. Receipts are obtained for all purchases. Personnel within the finance department carry out a monthly audit of the service users’ personal allowance records. Staff no longer use the service users’ personal allowance to buy the service user a birthday card. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 and 30. Quality in this outcome area is adequate. We have made this judgement using a range of evidence, including a visit to this service. Elsdon Mews provides service users with a well maintained place in which to live. However, due to there being eight people with diverse complex needs this is not always a calm peaceful environment. EVIDENCE: Although all service uses have individual bedrooms, due to the high care needs of the eight service users living at Elsdon Mews, there are only two lounges and this does not provide the needed space where loud behaviour is unobtrusive to other service users. In one person’s person centred plan it said “ a small home would make an enormous difference”. The keyworkers support the service users with personalising their bedrooms and specialist equipment has been provided where this has been recommended by the occupational therapist. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 19 Re-decoration has taken place in a number of areas of the home including the corridors, laundry, kitchen, sleep-in room and bathrooms. A specialist bathing facility has also been installed and new grab rails have been fitted to toilets. Staff said that as a result of the re-decoration the home was “much brighter”. The home is clean and tidy. Policies and procedures are available in relation to infection control. Throughout the inspection the staff demonstrated an awareness of infection control by using protective gloves and aprons where necessary. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from a well supported staff team and improvements to staffing levels ensure that the social and psychological needs of the service users are met. However, staff would benefit from further training to meet the diverse needs of the service users. Staff recruitment procedures protect service users. EVIDENCE: Currently there are two staff vacancies. This has not impacted upon the number of staff available on each shift and opportunities for service users to take part in leisure and community activities have not been affected. As previously mentioned the manager is currently recruiting for a full time enabler to work in the service. This will mean that staff will regularly be able to provide service users with 1:1 or 2:1 support with activities of daily living, leisure and community activities. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 21 Staff said that they had been provided with health and safety training but “not much else” in the last year. The manager has identified that she needs to develop a training needs analysis to help address this issue. Staff said that most of them had a supervision in January this year. Interactions between staff and service users were sensitive and respectful. Staff on duty clearly demonstrated an understanding of the service users method of communication and their health and personal care needs. It has been agreed with us that staff recruitment records can be held centrally by the organisation and therefore are not available in the home for inspection. However, the deputy manager confirmed that staff are only employed in the home after sufficient background checks have been carried out, which help determine their suitability to carry out their role. These checks include the receipt of a Criminal Records Bureau (CRB) ‘disclosure’, two written references, and confirmation of physical fitness. Staff said that each year a new CRB disclosure check is obtained for them. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. We have made this judgement using a range of evidence, including a visit to this service. While the manager provides good leadership, focussed on the best interests of the service users, monitoring systems need to be put in place to measure the success of the home in achieving its aims. Some improvements need to be made to fully protect the health and safety of service users. EVIDENCE: The manager is a registered nurse and has a number of years experience in a management role. She has only been in post since October 2007 yet in this short period of time staff commented that she had “turned the place around”. They also said that they felt more valued and more motivated. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 23 The views of service users and their families have not been formally sought. There was no evidence of internal quality audits taking place, other than the monthly locality manager checks and some health and safety checks being carried out by staff, such as testing the fire alarms. The manager has identified this as an area for improvement in the next year. There is a rolling programme of training for staff in health and safety matters and staff confirmed that this training has been kept up-to-date. Appropriate records are maintained of accidents and incidents. It was difficult to determine from records if all staff had received a fire instruction at the required intervals. The manager has identified this as a need and is planning to instigate a monthly fire instruction for all staff. One service user has bed rails attached to their bed. These can be a hazard if not used properly, regularly maintained and checked. There was no risk assessment available for them. During the inspection, when left unsupervised, one service user attempted to climb through the hatch in order to get into the kitchen. This potential hazard must be addressed. At the time of the visit the home was without hot water. This was being managed well by the service, however, we had not been notified of this incident through the correct reporting procedure, known as a “regulation 37” notification. Equipment such as gas appliances, hoists and fire detection and fighting equipment are regularly tested. However, records showed that the portable appliances had not been tested since January 2006. Elsdon Mews (26) DS0000000256.V356939.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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 x 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 X 2 X x 2 X Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA17 Regulation 17(2) Schedule 4. Requirement Menus must be in sufficient detail so that it can be determined that service users are provided with a varied, nutritious wholesome diet. This it to ensure that their health and well-being is fully promoted. Medication risk assessments must be regularly reviewed. This is to fully safeguard the service users. All staff must receive training in relation to the local authorities safeguarding adult’s procedure. A copy of this procedure must be available to staff. (Previous Timescale not met 31/08/07) Risk assessments must be updated following any incident. This is to fully safeguard the service users from abuse. Consideration must be given as to whether the needs of all of the service users can continue to be met within the current environment. (Timescale not met 31/12/07) Timescale for action 31/05/08 2. YA20 13(2) 30/04/08 3 YA23 13(6) 31/10/08 4 YA24 23(2)(a) 31/10/08 Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 26 5 YA35 18(1)( c ) 6 YA37 37 7 YA39 24 A training programme must be 31/10/08 implemented. (Previous timescale not met 31/07/08). The manager must notify the 29/02/08 Commission of any incident which affects the well-being of service users. The quality assurance 31/12/08 processes must be developed to include internal audits. This is to ensure the service is meeting its stated aims and objectives. The views of service users and their representatives should also be formally sought. (Previous timescale not met 31/12/07) The manager must implement the system, as planned, to make sure that all staff receive regular fire instruction and drill. The manager must make sure that the electrical portable appliances are tested annually. A risk assessment must be completed for the use of bed rails and for the incident discussed in the body of the report. 30/04/08 8 YA42 23(4)(e) 9 10 YA42 YA42 23(2)( c ) 13(4)( c ) 30/04/08 31/03/08 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. Refer to Standard YA6 Good Practice Recommendations The support plans should continue to be developed so that up-to-date information is available about each person’s health and personal care needs. Elsdon Mews (26) DS0000000256.V356939.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Elsdon Mews (26) DS0000000256.V356939.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. 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