Inspection on 23/03/07 for Fairfax Road

This inspection was carried out on 23rd March 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 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairfax Road 26/02/09

Fairfax Road 28/10/05

Fairfax Road 26/04/05

Fairfax Road 14/12/04

Fairfax Road 27/09/04

Fairfax Road 23/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Fairfax Road 19 Fairfax Road Leeds West Yorkshire LS11 8SY Lead Inspector Dawn Navesey Key Unannounced Inspection 23rd March 2007 11:15 Fairfax Road DS0000001449.V332985.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 Fairfax Road DS0000001449.V332985.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. Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fairfax Road Address 19 Fairfax Road Leeds West Yorkshire LS11 8SY 0113 2778842 F/P 0113 2778842 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) None Milbury Care Services Limited Mrs Linda Payne-Utley Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th October 2005 Brief Description of the Service: 19 Fairfax Road is situated at the end of a quiet cul de sac but within 2 miles of Leeds City Centre. There are a wide range of shops and leisure facilities within easy reach of the property. The home is a 4 bed roomed detached bungalow with a carport and large garden. The bedrooms are all single rooms with washbasins and decorated to individual taste and choice. Service users are encouraged to buy personal items for their own use, which helps to create a comfortable atmosphere within the home. There is a lounge and open plan kitchen/dining room allowing service users to choose either to participate in or to observe domestic activity within the home. There is a bathroom and separate shower room. There is also a separate laundry room. Service users are encouraged to make full use of the entire house and garden and the facilities within, including the television as well as video and music systems. The current charge at the home is £1013 per week. Additional charges are made for music therapy, toiletries, some leisure activities, holidays and taxis. Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk One inspector between 11-15am and 5-05pm carried out this unannounced inspection. The purpose of this inspection was to make sure the home was providing a good standard of care for the people living there. The people who live at the home prefer the term service user; therefore this will be used throughout the report. The methods used at this inspection included looking at care records, observing working practices and talking with service users and staff. Information gained from a pre-inspection questionnaire and the home’s service history records were also used. Before the visit, comment cards were sent out to service users, relatives and visiting professionals to the home. Two of these have been returned and this information has also been used in the preparation of this report. There were no visitors to the home on the day of the visit. Feedback was given to the senior support worker at the end of the visit. Thank you to everyone for the pre-inspection information, returned comment cards and for the hospitality and assistance on the day of the visit. Requirements and recommendations made during this visit can be found at the end of the report. Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The organisation must give service users an up to date contract showing the current costs for a place at the home. The manager must make sure that service users’ care plans have clear and specific detail for staff so that care needs do not get overlooked. The manager must make sure referrals are made to the relevant health professionals for any health needs of service users. Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 7 Handwritten entries on the medication administration record sheets must be checked and countersigned to avoid the risk of any errors being made. The practice of hand sluicing soiled linen must cease in order to reduce the risk of cross infection. Paper towels must be provided to ensure good hand drying hygiene. Two written references must be obtained for all staff to show that recruitment is properly and safely managed. Staff must receive supervision to make sure they carry out their job properly. Staff must receive training in infection control. They must also receive training in ageing in order to properly meet the needs of the service users. The manager must make sure that all staff receive fire training. 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. Fairfax Road DS0000001449.V332985.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 Fairfax Road DS0000001449.V332985.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, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users or their representatives have sufficient information available to make sure they can make a choice about the home. Service users have a pre admission assessment carried out to make sure the home can meet their needs. Service users do not have updated contracts showing the costs for the place at the home. EVIDENCE: The Statement Of Purpose and Service User Guide have been produced in an easy read format, using large print and pictures. They give detailed information on what the service can provide. These are both kept on display in the entrance hall of the home where families and visitors can have access to them. Each service user also has their own copy. Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 10 Service users have a contract with the organisation. However, the contracts do not have all costs listed in them. Service users’ needs had been assessed before they moved into the home to make sure the home could meet their needs. One service user said, “I like it here.” A relative who had written to the home, said, “Every day at Fairfax Road is open and welcoming to all.” Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments, in the main, provide clear detailed instruction on how service users’ needs are to be met. Service users are involved in the day to day running of the home. EVIDENCE: Service users have care plans, which, in the main, are detailed and give staff specific instructions on care needs. They have been developed from assessments of service users’ needs. However some care plans need more detail to make sure important care needs do not get overlooked. For example, a care plan on dressing and undressing says the service user needs one person to assist. It does not say how staff assist the person. Another care plan says the service user needs to use a hoist for moving and handling but does not say Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 12 how this is to be done. A service user who does not use verbal communication has a care plan on communication. However, the plan just says this person has no verbal communication, it does not say the other ways that the person communicates. However, the staff spoken to, have a good awareness of service users’ needs and can talk in detail about the support they give. A relative who returned a survey said, “There are 4 residents at Fairfax Road and each one is treated as an individual with their needs being met.” All staff are involved in developing the care plans and updating them as needs change. Staff said they had completed care plan and risk assessment training. The care plans are reviewed every three months. This is done by signing and re-dating the plans. There is no room on the documentation for any evaluation of the plans. If there are changes to a care plan, each care plan on the sheet has to be re-written. Service users have not had any formal reviews for some time. This would be a good way of involving relatives in the drawing up of care plans. Risk assessments have been completed for service users as part of the care planning process. These are all up to date and reviewed. The staff have recently started some person centred planning with service users. This work is on going but has already started to identify some future plans for service users such as trying new activities. This is good practice. Service users make choices on a daily basis about what to do, what time to get up or go to bed and what to eat. Staff are aware of how service users communicate their needs, even if they do not use verbal communication. Staff said they get to know service users likes and dislikes as they get to know them better. Staff were seen to respond to service users’ choices for different foods and drinks during the visit. Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers opportunities to service users for their personal development in addition to a good range of leisure activities. A good, healthy and varied diet is offered to service users. EVIDENCE: Service users are involved in a variety of activities. This ranges from college courses, shopping, going to the theatre or shows, bingo at the local parish centre, walks, and meals out. Once a month a music therapist comes to the home for music and sing-a-long sessions. Service users are encouraged to meet up with old friends and to keep in contact with their families. Staff said Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 14 that service users are known in the local community and use local facilities such as shops. Service users go to a local church. Service users enjoy activities in the home too. They have two cats they help care for and they maintain a bird table in the garden, making sure bird seed and nuts are provided through the winter months. One service user said she enjoyed watching the birds come to the table to feed. It is clear that service users enjoy art activity in the home as many pieces of work are displayed around the home. Staff said that service users enjoy rides out in the home’s minibus. However, the home has only one member of staff who can drive it so the organisation has decided to remove the mini-bus and put the funding into using public transport such as taxis and the access bus. Service users also attend a weekly Gateway club. Risk assessments have been carried out regarding this activity as all four service users like to go. The risk assessment states that three staff should go with the service users to make sure they are properly supervised. Staff said that two staff support service users when they haven’t got three on. These should be reviewed to make sure all service users’ needs are being met on this activity. All service users have an annual holiday that is individual to their needs. There are lots of photographs around the home showing the activities on the holidays. One service user said she likes flying and is hoping to go abroad again this year. Risk assessments are completed for holidays. This is good practice. Staff were seen to support people with courtesy and thought for their dignity, especially when supported with their meals and drinks. Staff said it was important to make sure service users are as independent as possible. They said they are encouraged to get involved in household tasks and to make drinks and snacks for themselves. There was lots of social interaction between the staff and service users. Staff always explained what they were doing and what was happening throughout the day. Menus are pre-planned at the home. However, if a service user wants something different to what is on the menu, this can be done. On the day of the visit, the evening meal had pasta as part of it. Staff said that one service user doesn’t like pasta so would have a jacket potato as an alternative. A good variety of food is available and staff try to make sure there is a good selection of fresh produce available. The lunchtime meal on the day of the visit was ham sandwiches and crisps followed by pots of rice pudding. When asked if they were happy with the food at the home, one service user said, “Oh yeah.” Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported properly with their personal care needs. Health care support is,in the main, provided in a way that meets service users’ individual needs. Service users are, in the main, protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Staff support service users with their personal care needs in private and with dignity. Care needs are dealt with quietly and discreetly by staff. Service users are well dressed in clothing appropriate to their age and needs. Staff have good knowledge of service users likes and preferences on personal care. Staff said that one service user likes to wear perfume everyday. This is Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 16 also documented in the care plan. In a letter to the home, a relative said, “The care and support given to my sister is second to none.” The care plans also have details of any health professionals that service users see. These included, GP, dentist, district nurse, podiatrist, optician and chiropodist. Records are kept of any health appointments and their outcome. Staff always accompany service users on all their appointments. A relative who had written to the home said, “My sisters health and happiness has greatly improved living in the smaller environment.” Service users are weighed monthly and this information is recorded. No service user is nutritionally at risk. However, during the lunchtime meal it was clear that one service user has difficulty with chewing and swallowing food. Staff said they had not made a referral for the advice of a dietician or speech and language therapist for this service user. This must be done to make sure the service user is assessed by one of these health professionals to make sure her needs are properly met. Staff have introduced breast screening for the service users. Each service user has a health care plan regarding this. However, staff have been carrying out breast examinations for service users. It is not clear that this has been agreed to by the service users or if staff have been trained to carry out this procedure. Service users must be referred to their GP practice regarding this screening to make sure their health needs are properly met. The home uses a monitored dosage pre-packed system for medicines. All staff take responsibility for the administration of medication and have been trained to do so. There are good ordering and checking systems in place, with a clear audit trail for any unused medication returned to the pharmacy. The medication administration record (MAR) sheets were checked and showed no errors. However, handwritten entries on the MAR sheets had not been checked and countersigned. This could lead to errors in medication administration. Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users or their representative’s concerns are listened to and acted upon. Service users are protected from abuse by the home’s policies and procedures on adult protection. EVIDENCE: The home has a complaints procedure displayed in the entrance to the home. This has been produced in an easy words and pictorial format to make it more accessible to all. Relatives who returned a survey card said they knew how to complain but had never had to make a complaint. Staff spoken to said they are aware of the complaints procedure and could locate the complaints book. The home has not received any complaints recently. Staff have now received training on the protection of vulnerable adults. They were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse. Good records are kept of service users’ finances and their monies are kept safe. Fairfax Road DS0000001449.V332985.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, 25 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable and safe environment. Some practices at the home increase the risk of the spread of infection. EVIDENCE: A tour of the home was carried out, accompanied by a staff member. The home is spacious and well laid out, providing sufficient room for all service users. Service users’ bedrooms have been decorated and furnished to a high standard and to suit them as individuals. The styles of the rooms show their interests and personality. Most of the bedrooms have recently been refurbished with fitted wardrobes and cupboards. Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 19 The home is very clean, fresh smelling and warm throughout. Fixtures and fittings are of a very good quality. There is a homely feel to the home and service users are encouraged to personalise their rooms and the communal areas of the home such as the lounge and dining room. There is a bathroom and a shower room, giving service users a choice of bath or shower. There is a hoist to assist those service users who need it. Rails have also been provided to assist service users when using the bathroom or toilet facilities. The home has a large, well-kept garden which service users make good use of, especially in the summer months. Clinical waste is, in the main, properly managed and staff wear protective clothing when attending to service users’ personal care needs. However, staff said they hand sluice soiled linen before it is laundered. This practice must cease as it increases the risk of cross infection. Soluble red bags must be used for soiled linen or soiled linen must go straight on to a sluice cycle of the washing machine. Staff have not received training in infection control but are able to say what infection control measures are in place. Liquid soap is available at all sinks, however disposable towels must be provided to make sure of good hand washing hygiene. Fairfax Road DS0000001449.V332985.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 adequate. This judgement has been made using available evidence including a visit to this service. Staff are competent to meet the needs of service users; they are, in the main, well supported and supervised. Service users are, in the main, protected by the home’s recruitment procedures EVIDENCE: There are staff on duty throughout the day and night. There are usually two staff on the morning shift, two staff on the afternoon shift and one additional staff member per day on occasions, depending on the needs and activities of service users. At night there is one member of staff. As mentioned in the Lifestyle section of this report some activities the service users do would benefit from having more staff to support them. Also, the needs of the service users may change as they are all over 65 and the staffing needs may increase as they get older. The manager should keep this under review to Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 21 make sure the current staff numbers is properly meeting their needs. A relative who returned a survey card said of the staff, “They do very well and are most co-operative and helpful.” Recruitment is, in the main, properly managed by the home; interviews are held, references and CRB (Criminal Record Bureau) checks are obtained before staff start work and checks are made to make sure staff are eligible for work. However, one member of staff had only one reference on file. Two written references must be obtained for staff in order to meet the recruitment standards. Staff’s training was mostly up to date. Good records are kept of staff’s training and when their updates are due. The manager assesses this to make sure training doesn’t get missed. Staff spoke highly of their training and the support they get from the manager. Staff have not, however, received training on the specialist needs of service users such as ageing. Also as mentioned in the section on the environment, staff have not received any training in infection control. Over 50 of the staff team have achieved an NVQ (National Vocational Qualification) in level 2 or above. All staff said they felt they have a very settled team and the manager is very supportive. Staff said they felt communication and teamwork within the home is good. Regular staff meetings are held. Staff receive supervision and have an annual appraisal of their performance. However, some staff, including the manager have not had regular supervision. This must be improved in order that all staff receive the support they need to carry out their jobs properly. This was brought up at the last two inspections at the home. Fairfax Road DS0000001449.V332985.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 good. This judgement has been made using available evidence including a visit to this service. The home is well managed, the interests of the service users are seen as important to the manager and staff and are safeguarded at all times. EVIDENCE: The home has an experienced manager who is currently undertaking her NVQ level 4 and Registered Managers Award. She expects to complete this in the next six months. She works alongside staff to make sure of good practice. She uses handover times when on shift to complete her management tasks. Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 23 The operations manager visits the home on a monthly basis to carry out regulation 26 visits. This involves talking to service users and staff about the home. A report of these visits is made showing details of any action to be taken to improve the service. In addition to this, the manager has recently sent questionnaires out to relatives asking for ways in which they can improve the service. A relative who returned a survey card said of improvements to the service, “You cannot improve on what they do they are brilliant.” Staff carry out weekly or monthly health and safety checks around the home such as fire alarms, emergency lighting, water temperatures and checks on the house vehicle. Maintenance records are well kept. Environmental risk assessments are completed and up to date. Fire training is not up to date for all staff according to the records observed. This health and safety matter must be addressed to ensure good practice from all staff. Accident or incident reports are completed. There is a section for follow up action to be taken after any accident or incident. This section had not been completed on all accident reports seen. The home has a comprehensive range of policies and procedures in place. Staff are given opportunity to read and become familiar with these during their induction. Fairfax Road DS0000001449.V332985.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 3 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 3 ENVIRONMENT Standard No Score 24 4 25 4 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X Fairfax Road DS0000001449.V332985.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 YA5 Regulation 5 Requirement The organisation must provide each service user with an up to date contract, detailing all charges. The manager must make sure that each service user has a clear and detailed care plan, which identifies all their needs, and how they will be met. The manager must make sure that referrals are made to the relevant health professionals for service users as needs arise. The manager must make sure that handwritten entries on the medication administration records are signed, checked and countersigned as correct. The manager must make sure that the practice of hand sluicing soiled linen ceases. The manager must also make sure that disposable towels are available for hand drying. The manager must make sure that two written references are obtained for all staff. The manager must make sure that staff receive training in DS0000001449.V332985.R01.S.doc Timescale for action 31/05/07 2. YA6 15 31/05/07 3. YA19 15 31/05/07 4. YA20 13 31/05/07 5. YA30 13 31/05/07 6. 7. YA34 YA35 19 18 31/05/07 31/12/07 Fairfax Road Version 5.2 Page 26 infection control and ageing. 8. YA36 18 The manager must ensure all members of staff have regular formal one-to-one supervision sessions. This remains outstanding from previous inspections of 26/04/05 and 28/10/05. The manager must make sure that all staff receive fire training. 31/05/07 9. YA42 13 31/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA33 YA37 Good Practice Recommendations The manager should keep the staffing numbers under review to make sure current staffing levels continue to meet service users’ needs as their needs change. The organisation should consider giving the manager some additional time to manage her management tasks. Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Fairfax Road DS0000001449.V332985.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!