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Inspection on 15/11/06 for Handley Drive

Also see our care home review for Handley Drive for more information

This inspection was carried out on 15th November 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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Discussions with service users confirmed that staff provided them with the necessary support and assistance to ensure that they were able to live a lifestyle of their choice. The Registered Manager demonstrated a sound knowledge with regards to the care needs of service users within his care, and was proactive in promoting both a high standard of care and the rights of the individual service user. General observations during the process of the inspection identified that staff interacted with service users in positive and professional manner and service users appeared comfortable within their environment. The home has recently implemented a new care plan of which was very informative and user friendly.

What has improved since the last inspection?

The Fire Safety Officer had made a number of requirements to ensure the safety of service users and individuals accessing the property. It was pleasing to see that work had commenced within this area. The Registered Manager confirmed that a number of requirements are still outstanding due to waiting for necessary funding. A requirement was identified in that last inspection report, for medication training to be provided for staff that are responsible for the administration of medicines. The Registered Manager informed the Inspector that staff had now received this training (First Response) of which, the certificate is valid for three years.

What the care home could do better:

Stoke On Trent City Council are required to ensure that all requirements identified in the Fire Safety Officers report are addressed within a reasonable timescale, to ensure the safety of service users, staff and other individuals accessing the service at Handley Drive. With reference to the homes medication system, the Registered Manager should ensure that all medicines are stored as directed by the manufactures.

CARE HOME ADULTS 18-65 Handley Drive 12 Handley Drive Brindley Ford Stoke-on-Trent Staffordshire ST8 7QZ Lead Inspector Dawn Dillion Key Unannounced Inspection 15 November 2006 10:30 Handley Drive DS0000028916.V318196.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 Handley Drive DS0000028916.V318196.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. Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Handley Drive Address 12 Handley Drive Brindley Ford Stoke-on-Trent Staffordshire ST8 7QZ 01782 517079 F/P ianhd.Clarke@swann.stoke.gov.uk 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) Stoke on Trent City Council Ian Clarke Care Home 11 Category(ies) of Dementia (3), Learning disability (11), Physical registration, with number disability (2) of places Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Handley Drive is a residential home located on the outskirts of Stoke On Trent, Staffordshire, the home is owned by Stoke on Trent City Council. The home provides a service for adults of both genders who have a learning disability, Handley Drive is also registered to accommodate three service users suffering with dementia and two with a physically disability. The two-storey property was built in the 1960’s, providing eleven single occupancy bedrooms, located on both the ground and first floor, en suite facilities are not provided. Bathrooms and toilet areas are located throughout the home and are in close proximity to both communal areas and bedrooms. The property provides two group living areas, on the ground floor there is a lounge dining area and a separate large lounge and separate dining area. There are also three bedrooms, laundry, office and walk in shower area on the ground floor. On the first floor there are eight further bedrooms, one assisted bathroom, one unassisted bathroom and also a shower room. There is a lounge/diner/kitchenette, which is used as a daily living skills training facility. Service users also have access to a garden at the rear of the property; ramp access and a grab rail are in place from the patio entrance. The home is located in a residential area and is in keeping with the local community. Staffing is provided on a 24 hours basis to ensure the total supervision and support of service users. Service users have access to relevant healthcare services if and when required. The fee chargeable for the service at Handley Drive is £689.00p per week. Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced Key Inspection of Handley Drive was undertaken in 6.5 hours. The inspection methodologies that were used to establish the quality of care provided and the effectiveness of the management of the home, to promote quality, diversity and best practices entailed the examination of the records relating the homes policies and procedures. Five service users were interviewed to ascertain their views and opinions of the service provided and the level of support and guidance offered, to ensure that they were able to live a lifestyle, of their choice with regards to their cultural and identified care needs. Nine comment cards were received from service users and eight from relatives providing information relating to the service delivery, of which has been incorporated within the contents of this report. A tour of the property was also undertaken to ensure that the environment and systems in operation were safe and conducive in meeting the needs of the service user group. The Registered Manager was present during the process of the inspection. The home provided a high standard of care. What the service does well: Discussions with service users confirmed that staff provided them with the necessary support and assistance to ensure that they were able to live a lifestyle of their choice. The Registered Manager demonstrated a sound knowledge with regards to the care needs of service users within his care, and was proactive in promoting both a high standard of care and the rights of the individual service user. General observations during the process of the inspection identified that staff interacted with service users in positive and professional manner and service users appeared comfortable within their environment. The home has recently implemented a new care plan of which was very informative and user friendly. Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 7 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 Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 This judgement has been made using available evidence including a visit to this service. The quality in this outcome area is “good.” This judgement is based on the examination of records pertaining to a service user who had recently been admitted to the home. The homes admission procedure ensured that prospective service users were provided with essential information, to enable them to establish whether the service provided at the home would be suitable to meet their identified care needs. EVIDENCE: The homes admission procedure ensured that prospective service users were provided with essential information, to enable them to establish whether the service provided at the home would be suitable to meet their identified care needs. The Registered Manager informed the Inspector that one service user had been admitted to the home since the last inspection visit. The examination of records pertaining to the newly admitted service user, identified that the home had conducted a pre admission assessment to Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 9 establish the care, social and physical needs of the individual and also identified, the necessary intervention of other health and social care professionals. Information obtained from the pre admission assessment provided the foundation for the development of the care plan and risk assessment. Prospective service users were able to visit the home prior to their admission, giving them the opportunity to look around the home and to meet existing service users and the staff team. A tea visit and an overnight stay were also offered. Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 This judgement has been made using available evidence including a visit to this service. The quality in this outcome area is “good.” This judgement is based on the examination of care plans; risk assessments and records relating to the intervention of other health and social care professionals. Minutes of service users meetings were also examined. Care plans provided comprehensive information, to ensure that service users care needs were met with regards to their cultural and chosen lifestyle. Staffs attitude and approach promoted service user involvement, appropriate support and guidance was provided, to ensure that service users were able to take controlled risks to live a normal life and to have positive life experiences. Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 11 EVIDENCE: Information obtained during the process of the pre admission assessment, provided the foundation for the development of a care plan, identifying all the aspects of the individuals personal, social and healthcare needs. Two care plans were examined of which provided comprehensive information, to ensure that service users care needs were met with regards to their cultural and chosen lifestyle, and also provided information relating to the level of support and guidance required to enable them to live a lifestyle of their choice. The Registered Manager had recently implemented a new care plan, which was more user friendly, published in plain English and pictorial. It is recommended that the size of the print should be enlarged to assist individuals who may have a visual impairment. Service users were actively involved in the development of their care plan and subsequent reviews. Monthly discussions with the service users were undertaken relating to their plan of care and where necessary, care plans were adapted to reflect the changing needs of the individual service user. Service user meetings were undertaken on a regular basis, giving the individual the opportunity to discuss the running of the home and to enable them to make decisions in areas affecting their lifestyle. The examination of minutes of service user meetings identified discussions relating to arrangements for Christmas and other social activities and domestic arrangements. Minutes were published in a pictorial format to promote the understanding of the service user group. Two risk assessments were examined of which, provided information relating to potential hazards and also included information with regards to the appropriate control measures to reduce or eliminate the identified risk, this enabled service users to take a responsible risk to promote normal daily living. Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 This judgement has been made using available evidence including a visit to this service. The quality in this outcome area is “good.” This judgement is based on the examination of records pertaining to service users and menus to establish the quality of meals provided. Discussions with service users and a staff member was also undertaken and general observations during the process of the inspection. Service users were provided with the necessary support and guidance to be involved in social activities within the home and to have a positive presence within their local community. Menus that were examined identified that service users were provided with a well-balanced nutritional meal to reflect their likes, dislikes and special dietary needs. Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 13 EVIDENCE: Information obtained from service users and the pre inspection questionnaire, identified that a number of service users attended day care services and also had access to the local college to enhance and learn new skills. There were no service users engaged in paid employment. On the day of the inspection a number of service users went Christmas shopping, some service users were involved in their own pastimes, of listening to music, puzzles, reading and engaging in conversation with staff. Discussions with service users confirmed that there were able to maintain contact with their family and friends who were able to visit the home at any time within reason. General observations during the process of the inspection, identified the routine within the home was relaxed with service users having freedom of movement with limited restrictions due to health, safety and respecting fellow service users privacy. Bedrooms that were inspected were pleasantly decorated and reflected the individual’s interests and personality. Observations and discussions with service users confirmed that staffs manner and approach promoted service users privacy. Bedroom doors were not fitted with a locking device to ensure the total privacy of service users, the Registered Manager informed the Inspector that this would be completed within the work commissioned to address requirements identified by the Fire Safety Officer. The home operated a three-week menu providing a well-balanced and varied diet, an alternative choice and special dietary needs were also identified on the menu. There were no service users within residence that required a special diet due to culture or religion. The Registered Manager informed the Inspector that a dietician was involved in view of promoting healthy eating and to provide professional support and advise for those service users who required a special diet. One service user was provided with specialist equipment to assist and promote their independence at mealtimes. Service users informed the Inspector that they enjoyed their meals. The Inspection of the kitchen identified that there was ample supplies of fresh and dry produce. Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 This judgement has been made using available evidence including a visit to this service. The quality in this outcome area is “good.” This judgement is based on the examination of care plans, risk assessments and discussions with service users. Service users had access to relevant healthcare services; care plans provided essential information relating to the level of support and assistance that was required to promote the individuals’ independence and welfare. The home medication system and practices ensured that service users received their prescribed medication as directed by the General Practitioner. Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 15 EVIDENCE: The examination of service users files identified that service users had access to relevant healthcare services and were provided with the necessary support from staff to access these services. On the day of the inspection one service user had visited the General Practitioner with the support of a staff member. Five service users were interviewed during the process of the inspection and all confirmed within their own mode of communication, that staff helped them to maintained their personal needs. Discussions with one service user identified that she was due to go into hospital for an operation. The home had produced a pictorial diary using real photographs of the service user; this provided a simplistic explanation of the operation and the procedures to follow. The examination of care plans identified that all healthcare visits were recorded. The home had a registration category that enabled them to provide a service for three service users suffering with dementia. The Registered Manager informed the Inspector that there was one service user in residence with dementia. Staff had received dementia awareness training and a Community Psychiatric Nurse was also involved to provide professional advice and support. The home operated the Boots monitored dosage system, the examination of records relating to the administration, storage, recording and disposal of medicines were mainly satisfactory. There were no controlled drugs in use, one homely remedy was identified within the medicine cabinet, it is recommended that authorisation for the use of this medicine is obtained from the respective General Practitioner, to ensure that no counter active effects will occur with regards to already prescribed medicines. The Registered Manager should also ensure that medicines are stored in accordance to the manufactures instructions. (This was addressed on the day of the inspection). With reference to the identified service user who had been prescribed inhalers, it has been identified as a requirement that the General Practitioner should be contacted regarding the appropriate dosage, timing and at what point they should be administered. Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 16 It was pleasing to see that a requirement identified within the last inspection report, relating to medication training had been undertaken by staff members who were responsible for the administration of medicines. Handley Drive DS0000028916.V318196.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 This judgement has been made using available evidence including a visit to this service. The quality in this outcome area is “good.” This judgement is based on the examination of the homes complaints procedure and systems in operation, to enable service users to share their concerns relating to the service provided to them. The home was in receipt of the Staffordshire Inter Agency Vulnerable Adults policy. The homes recruitment procedure ensured that the appropriate safety checks were undertaken to protect the service users. EVIDENCE: Information derived from the pre inspection questionnaire, identified that the home had received one complaint within the last twelve months, of which the Commission For Social Care Inspection were aware of, no other complaints have been received since. The homes complaints procedure was produced in a pictorial format and was displayed within the dinning room. The complaints procedure identified that complaints would be addressed with 28 days. Contact details of the Link Inspector for the service was also identified on the document. Service users informed the Inspector that if they were unhappy they would go to a staff member, in some instances service users indicated that they would go to the Registered Manager. Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 18 Information obtained from the service users comments cards relating to whom they would speak to if they were not happy, also identified that they would speak to the Assistant Manager and specific named staff members. The home was in receipt of the Staffordshire Inter Agency Vulnerable Adults policy. The homes recruitment procedure ensured that the appropriate safety checks were undertaken to protect the service users. All service users required some element of support with their financial affairs. Two records and funds pertaining to service users were examined, both of which were satisfactory, a record was maintained of all transactions and receipts were maintained. Handley Drive DS0000028916.V318196.R01.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 and 30 This judgement has been made using available evidence including a visit to this service. The quality in this outcome area is “poor.” This judgement is based on the inspection of the property and information obtained from the Fire Safety Officer. The design and layout of the property was suitable in meeting the physical needs of the service user group. Outstanding requirements identified by the Fire Safety Officer raise concerns of the safety of the property in the event of a fire. EVIDENCE: Handley Drive is located on the outskirts of Stoke On Trent, Staffordshire, the two-storey property was built in the 1960’s, providing eleven single occupancy bedrooms, located on both the ground and first floor, en suite facilities were not provided. Bathrooms and toilet areas were located throughout the home and were in close proximity to both communal areas and bedrooms. Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 20 The property provided two group living areas, on the ground floor there was a lounge dining area and a separate large lounge and separate dining area. There were also three bedrooms, laundry, office and walk in shower area on the ground floor. On the first floor there were eight further bedrooms, one assisted bathroom, one unassisted bathroom and also a shower room. There was a lounge/diner/kitchenette, which was used as a daily living skills training facility. Service users also had access to a garden at the rear of the property; ramp access and a grab rail were in place from the patio entrance. The home is located in a residential area and was in keeping with the local community. The Inspection of the laundry area identified that there was a manual sluice in use. In the interest of infection control, the Registered should seek advice from a Health Protection Nurse, regarding the appropriate sluicing facilities required in relation to the needs of the home. The examination of the previous inspection report and discussions with the Registered Manager identified that the Fire Safety Officer identified several areas of concerns relating to fire safety. The Registered Manager informed the Inspector that work had commenced with regards to the requirements identified by the Fire Safety Officer but had not been completed. It has been identified as a requirement within the contents of this report that the outstanding work must be completed and that consideration should be given in reviewing the homes fire risk, more frequently during this interim period. Handley Drive DS0000028916.V318196.R01.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): 34, 35 and 36 This judgement has been made using available evidence including a visit to this service. The quality in this outcome area is “good.” This judgement is based on the examination of records relating to a staff member that had recently been recruited and general discussions with Registered Manager. The homes recruitment procedure ensured that the appropriate safety checks were undertaken to ensure the safety and protection of service users. EVIDENCE: The Registered Manager informed the Inspector that there was currently one domestic vacancy, hours of which equated to twenty hours per week. The home had recently recruited one new Cook and two Bank staff. The examination of staff files identified that the homes recruitment procedure ensured that the appropriate safety checks were undertaken to ensure the safety and protection of service users. Information obtained from the pre inspection questionnaire identified that 46 percent of staff within the home had achieved the National Vocational Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 22 Qualification. Consideration should be given in enrolling more staff for the National Vocational Qualification to achieve at least 50 percent qualified workforce. The examination of training records and information derived from the pre inspection questionnaire identified that the home was committed to staff training and development. Further consideration should be given in commissioning diversity and equality training. The examination of staff records and discussions with one staff member confirmed that regular staff supervision was undertaken to provide staff with the necessary and support to undertake their roles and responsibilities. Handley Drive DS0000028916.V318196.R01.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 and 42 This judgement has been made using available evidence including a visit to this service. The quality in this outcome area is “good.” This judgement is based on the examination of the homes policies and procedures, discussions with service users, a staff member and the Registered Manager. Records and systems that promote the health and safety of service users and staff were also examined. The management style was open and transparent promoting the rights and independence of the individual service user. Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 24 EVIDENCE: Discussions with the Registered Manager identified that he was experienced in social care and had obtained relevant qualifications pertaining to his roles and responsibilities. He was also committed to periodical training to keep abreast of issues relating to learning disability services. The Registered Manager demonstrated a sound knowledge, of the care needs of the individual service user. With reference to quality assurance, questionnaires were distributed to service user and relatives; an ‘ideas’ book was also in operation. It has been identified as a requirement within the contents of this report, that the Registered Providers should ensure that monthly Regulation 26 visits are undertaken to monitor the service delivery. The examination of records and systems relating to the health, safety and welfare of service users and staff identified the following: Fire drills were undertaken on a regular basis, the last recorded drill was 28/09/06. A fire risk assessment was in place dated 17/05/06. Water distribution temperature accessible to service users were monitored on a regular basis with and average temperature of 430oC. The assisted bath was serviced 03/11/06. The gas boiler was serviced 01/06/06 A minor electrical installation was undertaken 28/07/05. Portable appliance test (PAT) was undertaken 24/01/06. Records were maintained of all accidents. Handley Drive DS0000028916.V318196.R01.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 4 X 2 X X 3 X Handley Drive DS0000028916.V318196.R01.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(1)(c) Requirement All service users to have a contract (previous timescale of 01/06/05 and 31/10/05, 31/3/06 not met) The outstanding recommendations made by Staffordshire Fire and Rescue to be addressed. (Previous timescale of 30/09/06 not met) The Registered Provider should ensure that monthly visits to the home are undertaken to monitor the service delivery. With reference to the identified service user who had been prescribed inhalers, the General Practitioner should be contacted regarding the appropriate dosage, timing and at what point they should be administered. An appropriate locking device should be fitted to bedroom door to ensure that service user have total privacy. Timescale for action 04/01/07 2. YA24 13(4) 04/01/07 3. YA39 26 23/12/06 4. YA20 13(2) 23/12/06 5. YA16 12(4)(a) 01/02/07 Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 27 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 YA6 YA32 Good Practice Recommendations All staff should have training in the proposed PCP system. Staff should be enabled to complete NVQ qualifications with over 50 achieving the award by the end of 2006. Consideration should be given in providing care plan in a larger print to assist individuals who may have a visual impairment. The manager should consider service users attending staff training where appropriate such as food and hygiene training. Consideration should be given to how information about complaints processes, feedback from quality assurance surveys and Commission For Social Care Inspection, inspections can be shared with service users, staff, relatives and stakeholders. Results of quality assurance surveys should inform future planning within the home. In the interest of infection control, the Registered Manager should seek advice from a Health Protection Nurse, regarding the appropriate sluicing facilities required in relation needs of the home. Authorisation for the use of homely remedies should be obtained from the respective General Practitioner, to ensure that no counter active effects will occur with regards to already prescribed medicines. Consideration should be given in reviewing the fire risk assessment more frequently, in view of the outstanding requirements identified by the Fire Safety Officer. 3. 4. YA6 YA12 5. YA22 6. 7. YA39 YA30 8. YA20 9. YA24 Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Handley Drive DS0000028916.V318196.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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