Inspection on 16/02/07 for Elsdon Mews (26)

This inspection was carried out on 16th February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 18 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) 15/02/08

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:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

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 Unannounced Inspection 16th February 2007 9:30am Elsdon Mews (26) DS0000000256.V332545.R02.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.V332545.R02.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.V332545.R02.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 Ms L Mullen (not yet registered). Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th December 2006 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 to the rear 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 £860.84-£900.29 Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day in February 2007 and was an unannounced key inspection. The inspection included information which had been provided by the manager in a questionnaire. Time was spent talking to the manager and some of the staff who were on duty. Time was also spent looking around the home, including the lounges, dining room/kitchen and bedrooms. A sample of records including the accident, fire log and complaints books were also looked at. The inspection focused on four service users, all of whom have different needs. This is known as “casetracking”, and this involved looking at what it was like, from their point of view, living at Elsdon Mews. The majority of people living at Elsdon Mews are unable to express their views on what is like living in the home by use of speech and so time was spent watching the staff’s care practices with them, checking that information obtained from discussion with staff and observation was clearly recorded in the care records. 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 could be fully met by the staff would be admitted. The food is good with lots of choices provided. Staff help service users with their personal care in a way that they prefer. The staff make sure that service users regularly receive health care checks and look after their medication safely. There is a good complaints procedure so service users and their families know that their views will be listened to and acted upon. Staff are provided with lots of training so that they can carry out their job well. Staff recruitment is good and this helps to make sure that only suitable people are employed to work in the home. The manager has lots of experience and gets on well with the service users. Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The information in the “Statement of Purpose” and “Service User Guide”, (the home’s brochures), have not been kept up-to-date. They are also not provided in an easy to understand way. This means that new service users might not know what to expect from living at Elsdon Mews. The service users relatives need to be provided with a copy of the contract so they know what their family members rights are. There needs to be more leisure activities provided for everyone. More opportunities need to be provided for service users to be involved in the daily routines of the home and to develop their independent living skills. Mealtimes need to be a relaxed experience for everyone. The staff need training so they know who to contact should they witness or suspect abuse. How the staff support service users with spending their personal money needs looking at. There are too many people with high care needs living in one environment. With the current space available and poor staffing levels this means that their needs cannot be fully met. The manager needs to develop a training plan so that she can make sure that everyone gets the training they need. All of the staff should get a regular private meeting with their manager, (known as a supervision), to make sure they continue to do their job well. Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 7 The manager should carry out more checks to make sure the service users are getting a good service. The manager should make sure that the home is safe for everyone living and working there 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. 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.V332545.R02.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.V332545.R02.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&5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with insufficient information on which to make informed decisions about whether the home will meet their needs. The care needs of the service users were fully assessed before moving to Elsdon Mews and periodically thereafter to ensure that the care offered continues to be appropriate. Service user’s representatives, as advocates on their behalf, may not be aware of their family members rights and conditions of residency. EVIDENCE: There is a Statement of Purpose and a Service User Guide which set out the aims and objectives of the home. However, these documents have not been reviewed since February 2002 and do not contain up-to-date information. The Statement of Purpose is available in a standard written format only. Provision of this in large print, and/or with pictures or on tape, would further help Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 10 prospective service users and anyone associated with the service to decide whether the home is suitable to meeting their needs. 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. Should a vacancy become available future admissions to the home would only take place if the service is confident the staff have the skills, ability and qualifications to meet the assessed needs of the prospective service user. Recently a social worker has re-assessed everyone’s care needs. A copy of the contract was available in the home for those people chosen to case track, however, this had not been signed by their relatives to show that they had read and understood the terms and conditions of residency. The contracts had also not been signed by the manager. Elsdon Mews (26) DS0000000256.V332545.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7&9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further development is needed to reflect the service users’ health and care needs in the support plans to ensure staff provide continuity of care. Whilst service users are supported to make decisions, the risk assessment process does not fully promote their independence and autonomy. EVIDENCE: Each service user has a number of support plans. These cover a range of issues such as bathing, getting dressed, eating and drinking and provide staff with guidance on what they need to do to meet the service users personal and health care needs. However, some of the plans have not been reviewed since 2004 and may no longer be current or appropriate. The manager agreed that Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 12 this is an area that needs to be addressed and is currently in the process of reviewing and up-dating all of the service user’s support plans. Where, due to a service users complex needs, they may become agitated, there are guidelines in place instructing staff of the best way to support the service user when this happens. However, these are not in sufficient detail to make sure staff provide continuity of care. Although the support plans contain a risk assessment element this is usually in relation to preventing a service user from taking part in a particular activity in order to keep them safe. For example: for some service users this means that they are not able to enter the kitchen. The risk assessment process should be used to look at ways of how this could be achieved safely. A social worker is currently in the process of completing person centred plans with all of the service users. An advocate is also involved with the service users in order to provide them with the support they need to make decisions about their lives. Elsdon Mews (26) DS0000000256.V332545.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16&17. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are not always able to lead active fulfilled lifestyles with their rights as individuals being respected. This means that their personal development and role as valued members of the community are not fully promoted. Service users are offered a varied menu with wholesome food, which promotes their health and well being, however, mealtimes are not always a relaxed experience. EVIDENCE: Service users are able to maintain their independent living skills to a certain extent. For example: one service user takes their clothing to the laundry for washing and another service user is involved in baking sessions. Staff try to Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 14 be flexible and provide a service that is as individual as possible. However, due to current staffing levels and the complex needs of the eight service users living at Elsdon Mews staff are not often able to support service users to take part in the daily routines of the home. This means that in practise, for example, the staff cook and prepare meals and do the weekly grocery shopping for the service users rather than involving them with this. Although two service users did have a holiday last year, due to staff shortages some of the service users were not able to have a holiday. The “enabler”, (who is a member of staff employed specifically to arrange and support the service users with activities), has been off sick for some time and their hours have not been replaced. This has meant that opportunities for people to take part in leisure and community activities have been severely limited. For some people this has meant that in a period of a week the only outdoor activity they have been involved with has been to go for a drive. Staff support the service users to maintain regular contact with their family and friends by arranging and accompanying them on visits. A social worker is currently exploring the possibility of some of the service users attending a day service where opportunities will be provided for them to take part in a range of community based activities. There is a varied 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 lunchtime meal was served by staff to service users. This was a snack type meal consisting of sandwiches and crisps. Staff sat with the service users during lunch and offered them support where this was needed. The majority of the eight 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. However, those service users who have special needs in relation to food complete their meals quickly returning to the dining area where the other group of people are still being supported to eat, and attempt to access their food. This detracts from creating a relaxed environment for everyone at mealtimes. Elsdon Mews (26) DS0000000256.V332545.R02.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. 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 using available 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 protected by the homes medication policies, practices and procedures. EVIDENCE: The way that people prefer to be supported is recorded in their support plans. Service users are supported by staff to receive regular health care checks including dental and eye checks as well as on-going GP and other health professional appointments where this has been identified as a need. Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 16 In response to some of the more challenging complex needs of the service users the manger 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. A speech therapist is currently involved in developing communication plans with everybody. The service users medication is regularly reviewed by their GP. The staff have assessed the service users as being unable to look after their own medication. This is stored for them in a secure location within the home and administered by staff. Staff who administer medication have received in-house training on the safe handling of medication. There were no unexplained gaps on the Medication Administration Record and a brief audit of medication held in stock against records indicated that service users are administered their medication appropriately. Elsdon Mews (26) DS0000000256.V332545.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22&23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The views of relatives, as advocates on behalf of the service users, are taken seriously and procedures are in place to take appropriate action to resolve concerns and complaints. Appropriate policies are in place to ensure service users are protected from abuse, however staff need further training to fully safeguard the service users. Staff practices involving the service users personal money do not fully protect the service users. 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. Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 18 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. Staff said that they would have no hesitation in reporting bad practise. Although some of the staff said they had completed training in the prevention of abuse the manager was uncertain as to whether or not all of the staff have as yet received training in the local authority safeguarding adults procedures, (formally known as Protection of Vulnerable Adults (POVA)). A copy of this procedure was also not available to guide staff on who they should contact should they witness or suspect abuse. Service users money is stored securely and detailed records of expenditure incurred maintained. However, there was an example of staff using a service users personal allowance, so that they could buy the service user a birthday card. In effect this service user is buying themselves a birthday card, instead of, for example, staff using the petty cash. As this service user is unable to consent to their money being used in this way, this is an inappropriate use of the service users personal money. Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 19 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&30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Elsdon Mews provides service users with a safe place in which to live, however, repairs and re-decoration are not addressed quickly enough to ensure the home is well maintained. Due to there being eight people with diverse complex needs this is not always a calm peaceful environment. The environment does not fully promote the service users independence. EVIDENCE: There are two communal lounge/dining areas and one kitchen. None of the service users have access to the kitchen and are unable to independently use this area as this is kept locked at all times. This is in order to prevent two of the service users who have specific behaviours in relation to food accessing Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 20 this area. This practise has been established as a result of there being insufficient staff on duty to safely supervise all of the service users. 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. 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. Refurbishment has taken place in one service user’s bedroom. However, despite it being identified over one year ago that the hallway needed redecoration this issue has not been addressed. The staff sleep-in room is also showing signs of wear and tear. The bathrooms need to be redecorated. The manager said that they were waiting for the new specialist bathing facility to be installed before this issue is addressed. The home is clean and tidy and 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.V332545.R02.S.doc Version 5.2 Page 21 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&36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels do not fully address the social and psychological needs of the service users. Staff need more regular supervisions to ensure the aims and objectives of the service are put into practise. Although training is provided there is no plan in place to ensure that staff receive the appropriate training to meet the needs of the service users. Staff recruitment practices protect the service users. EVIDENCE: Currently there are two staff on long term sick leave. As previously mentioned one of the staff is the enabler, whose hours have not been replaced. This has meant that opportunities for service users to take part in leisure and community activities have been limited. Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 22 Minimum staffing levels only have been provided. Given that there are eight people living in the home all of whom have very complex diverse needs, staff are not able to regularly provide people with 1:1 or 2:1 support with activities of daily living, such as being involved in meal preparation. Staff said that they had been provided with induction training as well as ongoing training provided by the organisation. In addition to NVQ level 2 training in care some of the staff have had training in relation to person centred planning and “managing behaviour that challenges”. However, there is no comprehensive training plan in place or records to confirm the training undertaken by staff. Staff have not had regular 1:1 supervisions. Staff offer caring and sensitive support to all service users. One recently recruited member of staff commented upon how much they felt the staff really cared about the service users. It has been agreed with the Commission for Social Care Inspection that staff recruitment records can be held centrally by the organisation and therefore are not available in the home for inspection. However, the 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 ‘disclosure’, two written references, and confirmation of physical fitness. Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 23 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 Quality in this outcome area is adequate. This judgement has been made using available 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. The health and safety of service users is not fully promoted. EVIDENCE: The manager has the required qualifications and experience and is competent to run the home. She has completed the NVQ level 4 qualification in management and is about to undertake the NVQ level 4 qualification in care. She has regularly completed a range of other training to up-date her knowledge and skills, including person centred planning and challenging Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 24 behaviour. There was obvious warmth between the manager and the service users and she has continually worked hard to make referrals to other health care professionals to ensure the service users health care needs are met. 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. There is a rolling programme of training for staff in health & safety matters provided by the organisation, however, record keeping in the home is poor and as previously mentioned there was little in the way of a training programme to determine who has completed what training. Appropriate records are maintained of accidents and incidents. Fire log records showed that fire instructions have been carried out at the required intervals, however the manager has not completed a fire risk assessment for the service. The manager highlighted a hazard with those beds in use which are on casters. There was no risk assessment to show what measures have been put in place to reduce the risk. Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 2 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 1 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 2 12 3 13 2 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 1 X X 2 x Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 26 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 YA1 Regulation 4 Requirement The Statement of Purpose and Service User Guide must be kept under review and be available in a suitable format to meet the needs of prospective service users. (Timescales not met 30/08/05 &31/03/06). Timescale for action 31/08/07 2. 3. YA5 YA6 5. YA9 Service user’s relatives must be 31/08/07 provided with a copy of the contract. 15 Service user care plans must be 31/08/07 kept up-to date and provide staff with clear step by step guidance. (Timescales not met 30/9/05 and 1/05/06. 13(4)(c)&15 Risk assessments must 31/08/07 continue to be developed to show how service users are supported to lead an independent lifestyle. (Timescales not met 30/09/05&31/05/06). 12(1)(a) Service users must be fully supported to develop independent living skills as part of living an independent lifestyle 31/08/07 15(1) 5. YA16 YA11 Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 27 6. YA13 YA14 16(2)(m) 7. YA23 13(6) 8. YA23 13(6) 9. YA24 23(2)(a) 10. YA33 18(1)( a ) A range of leisure activities must be offered to service users and these should reflect the service users likes and aspirations and be monitored through social care plans. 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. A review of the use of service user’s personal allowance must be carried out to fully safeguard the service users. Consideration must be given as to whether the needs of all of the service users can continue to be met within the current environment. Staffing levels must be maintained at sufficient levels in order to meet the care needs of the service users and to promote their safety. (Timescales not met 30/08/05 & 31/03/06). A training programme must be implemented. All staff must receive regular supervisions. The quality assurance processes must be developed to include internal audits to ensure the service is meeting its stated aims and objectives. The views of service users and their representatives should also be formally sought. A fire risk assessment must be completed for the building. A risk assessment must be completed for those beds on casters. 31/08/07 31/08/07 31/03/07 31/12/07 31/07/07 11. 12. 13. YA35 YA42 YA36 YA39 18(1)( c ) 18(2) 24 31/07/07 31/07/07 31/12/07 14. 15. YA42 YA42 23(4) 13(4)( c ) 31/03/07 31/03/07 Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 28 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 YA5 YA17 Good Practice Recommendations The service user contract needs to be signed by the registered manager. Mealtimes should be a relaxed experience for all service users. Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South Shields Area Office 4th Floor 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. Extracts may not be used or reproduced without the express permission of CSCI Elsdon Mews (26) DS0000000256.V332545.R02.S.doc Version 5.2 Page 30 - 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!