Inspection on 27/09/06 for Hadley Place Residential Home

This inspection was carried out on 27th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hadley Place Residential Home 03/10/08

Hadley Place Residential Home 05/10/07

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

CARE HOMES FOR OLDER PEOPLE Hadley Place 301-305 Anlaby Road Hull East Yorkshire HU3 2SB Lead Inspector Janet Lamb Key Unannounced Inspection 09:00 27 , 28 September 2006 th th X10015.doc Version 1.40 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 DS0000068362.V318559.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 Older People. 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. DS0000068362.V318559.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hadley Place Address 301-305 Anlaby Road Hull East Yorkshire HU3 2SB 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) 01482 212444 F/P 01482 212444 The Arches Limited Position Vacant – Gaynor Laing (Acting Manager) Care Home 27 Category(ies) of Dementia - over 65 years of age (27), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (27) DS0000068362.V318559.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Care to be provided for 6 named service users (names on CSCI files) in category MD who are under 65 years of age. One named service user under pension age can be cared for at the home 21st December 2005 Date of last inspection Brief Description of the Service: Hadley Place is situated on Anlaby Road approximately a mile from Kingston upon Hull City centre, offering residential accommodation for a maximum of 27 elderly people including 6 people with a mental disorder over the age of 65. In January 2004 six extra places were registered in single en-suite bedrooms, when three flats in an adjacent property, all above the lower ground floor kitchen in the home, were purchased and converted to bedrooms. There are now 21 single and 3 double rooms. Personal care is provided for all service users along with meals and laundry service. Accommodation is available on four levels with a passenger lift available from the lower ground to the ground and first floors. The second floor can only be accessed by a stairway. Any residents living on this top floor will need good physical mobility. The lower ground floor comprises of kitchen, dining room, sun lounge, walk-in shower, bathroom, office, bedrooms and toilets. The ground floor contains further bedrooms, lounges and toilets; the first floor has bedrooms, toilets and bathroom, while the second floor has more bedrooms, all en-suite, and a meeting room. To the rear of the home there is a small patio garden area with garden furniture and a ramp for wheel chair access to the back door. There is car parking for approximately nine cars, now that the car park has been extended to incorporate space belonging to the adjacent property. DS0000068362.V318559.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection of Hadley Place began at the end of June 2006 when a preinspection questionnaire was sent to the home requesting information about service users and their family members. The commission received the requested information on 8th August 2006 and survey comment cards were then issued to all service users and their relatives, their GP and any other health care professional with an interest in their care. This information obtained from surveys and information already known from having had contact with a number of people over the last few months, was used to suggest what it must be like living in the home. A site visit was made to the home on 27th and 28th September 2006 to test these suggestions, and to interview service users, staff, visitors and the home Manager. Some documents were viewed with permission from those people they concerned, and some records were also looked at. A total of four service users, and seven staff, including the Manager, were spoken to or interviewed during the site visit days and all of the information collected was checked against the information obtained through comment cards and details already known because of previous inspections and contact with the home. What the service does well: Service users are well assessed on entry to the home and are provided with a good care plan for staff to follow. They are well supported with health care that meets their needs and their expectations. They are protected from possible harm due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follow robust practices and procedures. Service users experience good levels of privacy, have their dignity maintained, and their right to make decisions respected. They are encouraged to maintain contact with family members and friends and enjoy visits from these people any time of the day, and they are encouraged to exercise choice and control over their lives. Service users enjoy good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition. DS0000068362.V318559.R01.S.doc Version 5.2 Page 6 They are confident their complaints will be listened to and acted upon, and they are satisfied with the protection from abuse that is available to them, in the form of procedures to be followed and in the form of robust recruitment and selection procedures and practices. Service users experience a safe, clean and well-maintained environment. They are cared for by competent staff that are managed by an efficient Manager. The Manager runs the home in the best interests of the service users, safeguards their financial interests, and maintains their health, safety and welfare. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000068362.V318559.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000068362.V318559.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (older people), 2 (adults 18-65). Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. EVIDENCE: Service users are fully assessed by their placing authority and also assessed by the home during their trial stay. Three service users gave permission for their files to be viewed and two of them could remember being included in the process of assessing their needs. Copies of the placing authority community care assessment documents and of the homes own assessment documents are held on files and contain relevant information to inform the care plans. DS0000068362.V318559.R01.S.doc Version 5.2 Page 9 The Manager confirmed the assessment process and care plans resulting from this are comprehensive in the information they hold. Service users also have contracts on files and where possible all documents are signed by them. There is also information available in the form of statement of purpose and service user guide, for service users to make a decision about the home before they consider moving in. Standard 6 is not applicable, as the home does not take service users for intermediate care. DS0000068362.V318559.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 (older people), 6, 7, 16, 18, 19 and 20 (adults 18-65). Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users receive good health and personal care and support, so their needs are well met. They benefit from good medication administration and from good levels of privacy and dignity within the home, so their health care needs are also well met. EVIDENCE: Three service users gave permission for their files to be viewed and all three were able to discuss the care and support they receive. One said, “My privacy and dignity is well respected, apart from when _____ wanders in to my room. She may need a more appropriate home to live in.” Another said, “People are never rude to me. I got a bit upset with the staff the other night though, about the bedrails, and I apologised later.” Other service users spoken to are generally satisfied with the levels of privacy, the support they receive and the lifestyle they have within the home. All service users have a care plan in place, which contains comprehensive details on what they require and the action staff must take to meet their DS0000068362.V318559.R01.S.doc Version 5.2 Page 11 needs. Only one of those spoken to could remember having a care plan though and all three said they had not seen theirs recently. Information was seen in diary notes that confirmed the care given and service users spoken to, except one, felt their needs were being well met and that they had everything they needed. The person that was not entirely happy with living in the home seemed to be dissatisfied with very particular aspects of the environment, relationships with other service users and with the situation involving their family’s opinions of their safety when going out. Issues were discussed with the person, but they requested no intervention. No one actually self-medicates in the home and staff that are trained to do so administer the medication for everyone. No one made any adverse comments about this, but said they were happy with the situation. Medication procedures were discussed with the Manager and the staff and medication handling was assessed as being satisfactory: - drugs are handled according to a clear audit trail, stored appropriately and administered according to medication administration requirements. Records held are appropriately maintained. Service users were observed receiving care and support from staff that considered their preferences and adhered to codes and policies on privacy and dignity. Those spoken to were of the opinion that they were very well treated. DS0000068362.V318559.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 (older people), 9, 12, 13 15 and 17 (adults 18-65). Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Outcomes for service users regarding daily life and social activities are good so they enjoy doing the things on offer, see visitors regularly, make their own decisions as much as possible and are positive about the food provision. EVIDENCE: Service users spoken to are satisfied with the routines of daily life in respect of their personal care needs, but only one is fully aware of the care plans in place to guide staff to meeting identified needs. Care plans were discussed with staff and all felt that service users’ personal needs are well met. Some service users said they enjoyed the pastimes available within the home or the community, but staff expressing their opinions felt there was a need to provide more in terms of one-to-one attention to them, and more for the younger service users living in the home. This was passed onto the Deputy Manager. Service users talked about a weekly outing on a Thursday using the home’s minibus, but they also pointed out that they don’t usually get off the bus once they reach their destination. Many have mobility problems and getting off the DS0000068362.V318559.R01.S.doc Version 5.2 Page 13 bus would involve major effort from them. One service user said, “The Thursday trips are very popular, there are always plenty that want to go, but the bus only takes nine.” Another said, “There are outings in the bus every week, but I couldn’t sit in the seat.” There are also theme nights held in the home, where perhaps a special meal is provided, a quiz is done, or a special sporting event on television is watched. Service users usually vote or come to a consensus on what that theme night will entail. On the day of the site visit a quiz night was to take place and service users could choose from chicken and chips or chop and chips for their evening meal. All activities and pastimes are listed on the activity plan posted on the wall in the lounge and in the office. Service users have input into this by making requests at meetings or in one-to-ones with staff. Service users receive visitors any time within reason, have contact with family members and friends and generally enjoy good communication with these people. They confirmed in conversation, and diary notes showed evidence of, contact and visits from their family and acquaintances. Visitors were observed coming and going during the site visit. Most service users handle their own finances or have family members that do so. Some have a small amount of money held in safekeeping and records are maintained to ensure transactions are properly carried out and recorded. Service users made no adverse comments about their financial arrangement. Service users consider the provision of meals within the home to be satisfactory. Those spoken to said they liked the meals and enjoyed the variety on offer. One service user said, “Sometimes my eating is poor, but the food is quite nice. I have no grumbles, we are all well fed.” Another said, “The food is quite nice.” The Manager and Cook compile menus after consulting service users on different dishes and choices, in residents’ meetings and in one-to-one discussions. They also seek opinions on food provision as part of the quality monitoring system operated within the home. Staff are keen to point out that in their opinion there is not enough choice at mealtimes, especially tea, but service users made no comments other than positive ones. Staff also commented on the produce purchased for mealtimes, stating the quality was not always good. Discussion with the Manager on this subject revealed there had been some dissatisfaction with items purchased a few months ago, but that reputable suppliers were now being used and there had been no issues recently with deliveries. DS0000068362.V318559.R01.S.doc Version 5.2 Page 14 Menus were not viewed on this inspection and the cook was not spoken to except in passing. She was observed asking service users what they wanted of the choices on offer for lunch and tea the following day. Provision of food is considered to be satisfactory. DS0000068362.V318559.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 (older people), 22 and 23 (adults 18-65). Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Complaint management and protection of service users are good, so service users are listened to and they are confident they will be protected. EVIDENCE: Service users were consulted about their experiences of making complaints and everyone said how they did not need to make a complaint because generally everything was fine. One service user said, “I have no grumbles and would only like for the relocation of the laundry to hurry up. It would help with the noise in my room.” Another said, “I have no complaints about this place, the food is good.” A third said, “It’s quite good here, I have no complaints. If there is we get over them.” Everyone spoken to expresses the view they see no reason to complain about anything. Staff were asked about their understanding of the complaint procedure because many of the questionnaires they returned seemed to imply their understanding was that the procedure was for them to make grievances known. However discussion with staff showed they do consider the procedure to be for service users and relatives. Staff were aware of the forms to fill out in the event of someone making a complaint, knew the procedure was posted on the service users’ notice board and explained they would take issues to the Manager or the Registered Provider if necessary. DS0000068362.V318559.R01.S.doc Version 5.2 Page 16 The record of complaints contained none for the past twelve months. Issues tend to be discussed in service users’ meetings or daily as they arise. Service users have also made known that they do not require monthly meetings, but prefer to hold one when they have issues to discuss. The last service user meeting was held in May 2006. Understanding of protection issues was also poorly portrayed on staff questionnaires, but discussion with them revealed they are aware of the vulnerable adults procedures in the home, though not of the ones compiled by the local protection of vulnerable adults co-ordinator. Staff training in vulnerable adults awareness is still being done by the group as a whole: seven staff have done such training with Age Concern, the rest (which includes new staff) have been booked to do the training imminently. DS0000068362.V318559.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 (older people), 24 and 30 (adults 18-65). Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is suitable for its stated purpose, and both cleanliness and maintenance are good, so service users enjoy a safe, homely environment. EVIDENCE: Some communal areas and four private bedrooms were viewed whilst interviewing service users and all areas are clean and satisfactorily decorated. Service users are satisfied with the cleanliness and tidiness of the home and those interviewed, except one, are satisfied with the room they are occupying. One service user would prefer their room to be away from the laundry area, which is sometimes noisy. Information was seen in procedures, which prevents the staff from undertaking the washing of laundry during the night and after a specified time, however. DS0000068362.V318559.R01.S.doc Version 5.2 Page 18 Generally the house is well maintained and the handyman deals with health and safety maintenance issues quickly. Records are kept of when an item or job is reported as needing attention and also when it has been completed. Generally the house is well maintained and the handyman deals with health and safety maintenance issues quickly. Records are kept of when an item or job is reported as needing attention and also when it has been completed. There are two cleaning staff on duty throughout the day as seen at the time of the site visit, and despite some staff questionnaires stating the cleaners often cover care vacancies or sickness to the detriment of the home, there is no evidence to show this to be so. What was pointed out in interviews with staff was their view that cleaning staff are not always adequately trained to do caring roles. Staff feel the service users do not always receive the best care because of this. The home could offer all staff the same training provided to carers to ensure cleaning staff are appropriately trained should they be called on to cover care duties. DS0000068362.V318559.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 (older people), 32, 33, 34 and 35 (adults 18-65). Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing complement and competence is only adequate, and improvements can be made in staffing levels and qualifications, so that the right number and skills mix of staff meet service users’ needs. Recruitment and training opportunities for staff are good and so carefully selected workers that are equipped with the awareness to do the job care for service users. EVIDENCE: Discussion with service users revealed they are of the opinion that staff are usually quite busy throughout the day, and that there are usually four on a shift. Also that when there are only three on a shift the workload is too much to handle. Staff are also of this opinion and expressed it in their interviews. Inspection of the staffing rosters show that for two weeks (w/c 25/09/06 and 02/10/05) staffing figures, including those of a 17 year old, the Deputy and some of the Manager covering shift, totalled 497 and 491 hours respectively. The “Residential Staffing Forum” figures calculated for the numbers of older people and the numbers of people with mental health issues actually in the home on the day of the site visit shows there to be a shortfall of 13.89 and 19.98 hours over the two weeks, and 35 of these hours in each week was worked by a carer under 18 years old and therefore these hours cannot be considered as being used to provide personal care. It is understood, from DS0000068362.V318559.R01.S.doc Version 5.2 Page 20 staff, that the person highlighted on roster to work an early shift, actually works most of the shift in the kitchen. It is clear that the home has been running on a shortage of staffing hours. The Manager explained that vacancies have been advertised and interviews have been held. Appointed staff are awaiting Criminal Records Bureau (CRB) clearance and can then begin working in the home. The Manager has covered some shifts, as has the Deputy, but these have been included in the calculation of hours provided in the two week’s rosters, and still there has been a shortfall. The Manager hopes to have new staff on shift by 23/10/06. Information provided to the commission prior to the inspection, from staff interviews and discussion with the Manager, and from staff training records shows there to be currently 2 with and 3 completing NVQ level 2, from a total of 16 care staff – 31.5 . Efforts need to continue to ensure a target of 50 is achieved. This has been diminished due to 5 care staff with the qualification moving to other jobs over the last few months. It is understood that two newly recruited staff, mentioned above, already have NVQ 2, and the percentage figure will rise again when they begin in post. Other training undertaken by staff, and verified from conversations with them and the Manager and seen in training records, includes mandatory courses in fire safety awareness, first aid, medication administration, moving and handling, dementia care and challenging behaviour. Where there was considered to still be lack of training and awareness in mental health awareness and in infection control, due to staff interview and questionnaire information, it was proven from discussion with the Manager and information already received by the commission following the last inspection, that staff have undertaken appropriate training in both of these areas. Refreshers in all training courses and dates when they will be required have been identified and will be arranged appropriately. There is a robust recruitment and selection policy and procedure to follow and staff files seen with their permission contained the required information as listed in schedule 2 of the Care Homes for Older people National Minimum Standards, Care Homes Regulations. Staff in interview were unsure of their CRB status, but it was determined that everyone has a valid CRB clearance either with the home or with the Humberside Youth Association, depending on who their employer is. DS0000068362.V318559.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 (older people), 37, 39 and 42 (adults 18-65). Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The management of the home is effective and the health, safety and welfare of service users and staff is satisfactorily maintained, so that service users know the home is safely run in their best interests. EVIDENCE: There is a new Manager in post that has the required qualification in ‘Care Management,’ and many years experience working in care homes and in a managerial role. She is effectively managing the home at the moment and has made an application to become the Registered Manager, interview pending. The home has a system for assessing quality of care that includes themed monthly audits, which follow a timetable for the year. There are some daily checklists to be followed and these contribute to the monthly themed audits. DS0000068362.V318559.R01.S.doc Version 5.2 Page 22 The Deputy Manager is responsible for ensuring these audits take place, while the Manager carries out annual survey quality checks using questionnaires. All of the collated information is represented in an annual report, which shows the home’s percentage performances. This is displayed on the home’s notice board each November or December. Staff are aware of the quality audits and some assist in gathering information. Service users are also aware of surveys and audit checks but do not fully understand the implications of systems. Most service users within the home handle their own finances or have family members that do so. Those spoken to were satisfied with the financial arrangements in place for them: one said, “My daughter has power of attorney for me and I receive my personal allowance each week. I pay for my own chiropody and ask a friend to bring a few things in for me. I’d like to know what I have in the office at the moment.” Another service user said, “I have my personal allowance, so much, and my lad tops up my money when it gets low. It’s a good arrangement, I go to the office and ask for my money.” Records for money held in safekeeping within the home are maintained, though these were not inspected. There are policies, procedures and guidelines on handling finances, assisting service users to make purchases and on such as receiving gifts etc. to protect service users from financial harm. Health and safety issues were discussed with the Deputy Manager and staff and generally the workforce has a good understanding of their responsibilities as employees. They are aware of the polices and procedures manual, sign copies of documents on reading them and report any health and safety issues to the handyman, as soon as possible. Fire safety was inspected and proved to be effective and up-to-date. Extinguishers were serviced in September 2006, weekly checks on the detecting equipment are carried out and recorded, and fire drills are held every two or three months and are also recorded. There is a fire risk assessment in place and the last full fire safety check by the local fire brigade was in April 2006. There are Control Of Substances Hazardous to Health (COSHH) information documents held for each product used in the home, which cleaners sign on reading. Cleaning products are safely locked away in the cleaning store cupboard and staff spoken to are aware of their responsibilities in respect of safe use of materials. Practice was observed to be good. There is one portable hoist within the home, which two service users use in the main. One of them expressed a view that the hoist does not completely suit them, because of their particular physical needs, while reports came from the Manager that the other person finds it uncomfortable if they are held in the hoist too long. This could not be verified, as the service user concerned was DS0000068362.V318559.R01.S.doc Version 5.2 Page 23 not present in the home. Staff use the equipment as effectively as they can to ensure safety and comfort for both service users and are aware of the implications for both of them when using it. The hoist is maintained twice yearly: March and September 2006 and the March safety certificate was available for viewing, but September’s had not yet been received. There are checks on the water temperature on a regular basis and these are recorded: the last checks being done on 11/09/06. The handyman has recently identified the need to strip down and clean all of the hot water safety temperature control valves and has completed the work. A full Legionella test was completed 22/07/06 and resulted in a negative reading. Staff have safe working procedures and guidelines to work to and either supervise or assist service users to take a bath or shower according to their wishes. Service users spoken to are satisfied with the arrangements for their personal care, some having a high dependency on staff. One said, “I only need support – to hose me down. There is help there if you want it.” Overall there is good evidence to show that the home is well managed and service user and staff have their health, safety and welfare well protected. DS0000068362.V318559.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 Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000068362.V318559.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No. 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 OP27 Regulation 18 Requirement The Registered Provider must ensure that at all times suitably qualified, competent and experienced persons are working in the home in such numbers as are appropriate for the health and welfare of the service users. Timescale for action 31/12/06 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 OP28 Good Practice Recommendations The Registered Provider should ensure there is a minimum of 50 care staff with NVQ Level 2, working in the home. DS0000068362.V318559.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000068362.V318559.R01.S.doc Version 5.2 Page 27 - 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. 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