Inspection on 02/08/06 for Hartington House

This inspection was carried out on 2nd August 2006.

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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hartington House 26/09/07

Hartington House 16/01/06

Hartington House 16/08/05

Hartington House 28/02/05

Hartington House 29/09/04

Hartington House 11/03/04

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

CARE HOME ADULTS 18-65 Hartington House 14 Hartington Road Heaton Bolton Lancashire BL1 4DP Lead Inspector Lucy Burgess Unannounced Inspection 2nd August 2006 10:00a Hartington House DS0000009315.V297661.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 Hartington House DS0000009315.V297661.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. Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hartington House Address 14 Hartington Road Heaton Bolton Lancashire BL1 4DP 01204 410854 01204 493126 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) Perpetual (Bolton) Ltd Mrs Tricia Varey Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 16th January 2006 Date of last inspection Brief Description of the Service: Hartington House is a small care home providing residential care for up to 5 people with mental health needs. The fees range from £488.00 to £1036.00 this is based on assessed needs. The home is part of a small group of two homes (the other being Somerset House). Both homes share the same staff team and are situated near to each other in the residential area of Heaton in Bolton. There is a small office at Hartington House, although the main office base for the two homes is at Somerset House. A local company, Perpetual Care, owns the home, with the day-to-day management carried out by the Registered Manger. Hartington House is an end terrace house, consisting of 5 single bedrooms and communal areas. The house is close to a main road leading into Bolton town centre and is accessible to local amenities and public transport. Residents are generally of a younger age range at Hartington House than those at Somerset House. Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit to the home was unannounced and took place over one day. The inspector spent time looking round the home, viewing records as well as talking with residents and staff. Discussion and feedback was also held with the Manager. The home is registered to provide accommodation for 5 people. At the time of the visit there were 2 vacancies. Although the inspection was unannounced the completion of a pre-inspection questionnaire was requested, along with feedback surveys from residents, relatives and health professionals who are involved with residents. The inspector received 3 completed surveys from 2 social workers and 1 health professional. Comments have been added to the report. All the key standards were looked at during this inspection visits. What the service does well: What has improved since the last inspection? Changes have been made to the environment. The hall, stairs and landings have been redecorated, the lounge has been redecorated as well as having new furnishings and bedrooms have had new flooring fitted. This has made some improvement to the home. Further work is planned to bring all areas up to a reasonable standard. More information is now being recorded with regards to the monitoring of food intake and weight with one resident where there have been concerns. This information helps staff to support the resident making sure that he stays healthy and well. Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 6 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. Hartington House DS0000009315.V297661.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 Hartington House DS0000009315.V297661.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this judgement area is good. This judgement has been made using available evidence including a visit to this service. Relevant assessment information is gathered to enable the home to make an informed decision about the suitability of placement ensuring they are able to fully meet the identified needs. EVIDENCE: At present there are only 3 residents living at Hartington House. The Manager has recently received a referral for a fourth person to move into the home. So that information could be gathered both the Manager and Support Worker went to meet with the service user, a family member and a mental health professional currently involved with the care. This enabled them to ask any relevant questions about the needs of the individual as well as gather some background information. Further details were also provided by the CPN and social worker involved. An opportunity was made available for the service user, social worker and CPN to visit and look round the home as well as meet with the staff and residents. Once all the information had been gathered that Manager was then able to make an informed decision about the suitability of the placement and whether the home is able to meet the identified needs. Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 9 This referral has been accepted therefore the Manager had prepared a ‘precare package and costing’, which has been submitted to the funding authority for agreement. This outlines what support can be offered based on the assessed needs. As some concerns have been highlighted in relation to health care, the Manager has also identified additional staff training to support this. This has been provisionally booked and will coincide with the service users move into the home if agreed ensuring staff are fully aware of the support to be provided making sure that the service user is safe. The placement would initially be for a short-term period and then reviewed to establish whether it was working well. All relevant parties would be involved in the decision making. Hartington House DS0000009315.V297661.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this judgement area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments were detailed and reflected the care needs of residents providing staff with clear information about how needs should be met. Residents appeared well cared for and were involved in making decisions about their lives. EVIDENCE: Each of the residents living at Hartington House has a diagnosed mental health problem. Two of the residents living at the home are there under a formal discharge programmes (CPA), which has been agreed by mental health professionals. Any concerns identified could result in residents being returned to hospital ensuring risks are minimised and individuals are protected. Residents each have a care file that contains a number of documents relevant to their care and support. One of the files was examined as during the previous visit issues had been identified. Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 11 Information was seen to include a front sheet, detailing the residents’ personal details along with the names of their next or kin, social worker, GP and consultant. Other information included a care plan, CPA review minutes, incident reports, assessments for aids and adaptations, risk assessments, professional visits, correspondence and financial information. Additional records continue to be maintained with regards to daily evaluation sheets and weekly weight records. Care plans are reviewed on a six monthly basis and where possible residents had signed to acknowledge their agreement. Previous issues, which had been raised regarding the monitoring of this resident, had been addressed. Concerns had been identified in relation to the monitoring of meals and weight as this had previously caused concerns due to self neglect. The staff team now ensure that records are made of all meals taken both at the home and when spending time at the second home, Somerset House. Weekly records are also made of weights, these showed that the residents weight was stable. Action had also been identified on the care plan with regards to what action to take should staff note a change and there was evidence of weight loss. Risk assessment had also been undertaken. These focused on the specific needs of residents, for example; the use of a mobility scooter, nutritional needs, behaviours, language and cooking. Whilst assessments had previously been reviewed the records stated that this was on-going. The Manager must ensure that assessments are reviewed along with the care plan on a 6 monthly basis or more frequently if needs change. This should be evidenced on the assessment. Formal reviews continue to be held with relevant health care professionals so that mental health needs of residents are monitored. Minutes of these meetings are held on file. Additional support and advice is also provided form social workers and community psychiatric nurses (CPN) should this be needed. As the home is relatively small, informal day-to-day contact is made between residents and staff with the views and opinions of both parties being easily aired. From general discussions and observations it was clear that residents continue to enjoy the company of staff. Interactions with staff were seen to be open and friendly. The staff team has been stable and team members were found to have a good awareness of individual needs. Feedback from one social worker who has made placement at the home was, ‘I have found the home to provide a high quality of care for my client and all interactions have been professional’. Hartington House DS0000009315.V297661.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this judgement area is good. This judgement has been made using available evidence including a visit to this service. The lifestyle of residents’ varies depending on their choices and preferences. Routines include accessing the local and wider community enabling them to increase their independence as well as meet with family and friends. Support is offered where required. A variety of meals are offered including specific dietary needs. EVIDENCE: Each of the residents currently living at Hartington have very different skills and abilities. Each follow their own routines, which are in the main independent of each other. As the home has increased their staffing levels support can be offered on a 1-2-1 basis. Recent activities have included residents going out together visiting Chester Zoo as well as having a picnic in the local park. Other activities have included visiting a local museum, watching the bowling in the park, cinema, having a drive out and one resident has bought tickets to go to a Cliff Richard concert. Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 13 One of the staff members has arranged a notice board displaying leaflets from local places of interest. These are to provide the residents with some ideas for day trips etc. As the home has a vehicle this would be used when taking part in such activities. Each of the residents also like to spend time relaxing at home. One resident prefers to spend time at the second home, Somerset House and will often visit the residents there. Whilst others will relax watching television, do some writing or help staff around the home. The inspector was told that the home is to have the Internet set up This would be available to the residents enabling them to look at things of interest as well as learn new skills. Residents receive their mail unopened, however do receive support from staff should they need to or a response is required. As previously identified the practice of providing keys to rooms continues however residents are not routinely given a key to the front door due to areas of risk and in the main the home being occupied. Each of the residents continue to maintain contact with family and friends. Visits take place both at the home or with residents visiting family members. Contact is made on a regular basis. Due to the needs of some of the residents specific arrangements are in place with regards to home visits, these are monitored and reviewed. Arrangements with regards to meals are informal as residents rise at different times and have different routines. Each of the residents are encouraged to prepare there own breakfast and lunch with the evening meal being prepared by staff with assistance from residents if they wish or there is an occasional take-away. The inspector looked at the food available, this included fresh and frozen vegetables, fruit, cakes, yogurts, ready meals and fresh meat. A number of halal items were also available as one of the residents follows a halal/vegetarian diet. An issue identified at the previous visit with regards to the monitoring of meals and weight of one resident had been addressed with records completed in relation to food intake and periodic weight records. Hartington House DS0000009315.V297661.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this judgement area is adequate. This judgement has been made using available evidence including a visit to this service. Residents health and personal care needs are consistently met ensuring their well-being is maintained. Relationships with mental health professionals are effective and provide support networks for the residents ensuring their health needs are promoted. The medication system is clearly managed and audited ensuring residents are protected and practice is safe. EVIDENCE: Each of the residents are independent and able to address their own personal care needs however it is necessary for staff to offer prompts, encouragement and assistance where necessary as at times this is an area which is neglected due to the behaviours of residents. Residents tend to make their own decisions in relation to the daily routines generally spending time in the communal areas of the home, taking part in outside activities or spending time in the privacy of their own room. Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 15 Through discussions with the manager and staff it was evident that they have a good understanding of the physical and emotional needs of the residents. Health care professionals are accessed for additional support and advise ensuring sufficient support and monitoring is provided in meeting the needs of residents. This has included the occupational therapist, incontinence nurse, assessments regarding aids and adaptations and psychiatric services. The home also has support from a mental health advocacy group, MHIST. Meetings continue to be held on a monthly basis and provide residents with an opportunity to discuss any issues they have as well as receiving additional support. Formal reviews as required under the discharge programmes are held. Discussion includes the residents’ stability, progress or concerns in relation to their mental health. Further information is also recorded within the care plans outlining the specific support needs of individuals and how they are to be met giving clear direction to those offering support. Records are made of all professional visits and appointments, which include community psychiatric nurses, GP, dentist, hospital etc. Each resident has access to all NHS entitlements as and when they are needed. Support is offered for appointments. The medication system was examined. This was found to be safe and records had been completed in full. Records are made of all items delivered and returned to the supplying pharmacist. The home carries out internal audits on a monthly basis to check that records are complete and if any refusals have been made. Further checks are also carried out be the pharmacist. Residents’ medication is also regularly reviewed with health professionals ensuring the stability of their mental health. At present none of the residents in receipt of medication self-administer. One resident refuses all medication prescribed. The relevant health professionals and staff monitor this. Feedback was received from a GP and 2 Social Workers who have placed residents at the home. Each confirmed ‘Yes’ in the survey to being able to see the residents in private, that they were satisfied with the overall care, there was clear communication and that they were kept informed, that medication was appropriately managed and that staff had a clear understanding of the residents needs. Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this judgement area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place in relation to the protection of service users as well as responding to their concerns. On-going training has also been provided ensuring staff are aware of what action to take and the residents are protected. EVIDENCE: The home has copies of the Local Authorities Vulnerable Adults Policy and Safe Guarding Adults Procedure along with their own policies and procedures. All but four of the staff have received formal training in this area. Arrangements have been made by the Manager for the remaining staff to attend the course. Since the last inspection there have been no issues or concerns raised at the home or with CSCI. As previously identified the home also has additional policies and procedures in relation to the protection of residents. These include whistle blowing, aggression, service users finances and missing persons. All staff have a Criminal Record Check in place. A written procedure is also in place with regards to the handling residents’ money. Records are made of all transactions as well as receipts being held. A random sample was checked, no errors were found. Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this judgement area is adequate. This judgement has been made using available evidence including a visit to this service. Although some work has been carried out to enhance the home further attention is still needed to ensure the health and safety of both residents and staff as well as improve the appearance of the home. EVIDENCE: Hartington House is a small home set within a residential area of Bolton. Accommodation consists of 2 lounges, one of which is the staff sleep-in room, a dining kitchen, 2 bathrooms and 5 single bedrooms. There is also a staff office on the second floor. Those wishing to are able to personalise their room to their liking. Since the last visit there has been further redecoration and improvements made to the home. Work has included: • Redecoration of the hall, stairs and landings, • New door handles and locks to bedroom doors, • New window blind in 1st floor bathroom and new tiling • New flooring to the office and 2 bedrooms • Front door repainted Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 18 • • • • Garden tidied and furniture provided Redecoration of large lounge, new suite, ornaments and rug New oven in the kitchen Backyard had been repainted This work has improved the environment with communal areas having a more homely feel. Further work was identified. This included; • One bedroom had been painted however not completed, nor had the woodwork been painted. • A further bedroom was in a poor condition. This was in the main due to the behaviour of the resident. The room needed redecorating, new flooring, furniture securing, radiator re-fitting to the wall and curtain pole securing. • There was no bulb or light shade on the 1st floor landing. This was addressed during the visit. • There were no hand-washing facilities in the laundry. • The outside fascias need repainting • The damp in one bedroom needs addressing Through discussion with the Manager it was noted that some of these areas had already been identified and work planned, particularly to the bedroom in poor condition. It was also discussed about the fascias being replaced however this work may not take place until 2007. The organisation now employs their own handy men, any work required is passed to them and scheduled for completion. Aids have been fitted within the home to provide assistance for one resident who had difficulty with his mobility. Handrails have been fitted at the front door, an extra handrail to the stairs and a grab rail in the bathroom. During the visit the home was found to be clean and tidy, however one bedroom did have a strong odour due to issue around incontinence. Whilst an assessment had been undertaken and aids provided issues were still on going. The Manager may wish to consider changing the mattress as well as ensuring that it is protected as this may reduce the level of odour within the room. Staff carry out most of the domestic tasks however where possible residents are also encouraged to assist. Hand washing facilities had not been provided with the laundry, the Manager must ensure that these are in place to prevent cross infection. Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 Quality in this judgement area is good. This judgement has been made using available evidence including a visit to this service. The organisation is clear about its responsibilities when recruiting new staff as well as providing training opportunities for staff ensuring they are equipped with the knowledge and skills in meeting the needs of service users as well as ensuring their safety and protection. EVIDENCE: Staff at Hartington House also work at Somerset House, which is where the main office is situated. Individual staff files are held at Somerset House therefore were not available for inspection. This standard will therefore be addressed at the next inspection at Somerset House. There have been no new staff since the last visit. In relation to training the organisation has become involved with Bolton Partnerships, which enables them to access training opportunities. The Manager has also received a copy of the North West Skills for Care Training Directory, which provides information on courses available within the region. Courses have been identified in moving and handling, fire safety, 1st aid and protection of vulnerable adults, with dates and staff scheduled to attend. Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 20 Additional training such as NVQ level 2 and 3 have also been made available to staff. As identified earlier in the report the Manager has provisionally booked some training specific to the health care needs of a new prospective resident, ensuring that the staff are aware of the support to provide should he move into the home. The Manager must ensure that specific training with regards to the needs of resident and in relation to protection are completed by all staff including bank staff and that evidence is placed on file, ensuring they are clear of the procedures to follow. Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this judgement area is adequate. This judgement has been made using available evidence including a visit to this service. The overall management of the home is consistent and reliable for the people living there. Systems are in place for the reviewing of the service provision along with satisfactory arrangements with regards to providing a safe environment however could be improved in some areas. EVIDENCE: The Residential Manager is responsible for the day-to-day management of both units, Hartington House and Somerset House. Training with regards to the NVQ level 4 has previously been completed. At present she is completing the final units for the Registered Manager Award. On completion copies of certificates should be forwarded to the CSCI. The Manager expressed that she feels fully supported in her role by the Registered Provider. She receives regular supervisions and appraisals as well meeting on a more informal basis. Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 22 In relation to the monitoring of the service, visits are undertaken by the Providers in line with Regulation 26 and reports completed and held at the home. Other feedback is sought through the health care reviews of residents where staff meet with health and social care professionals. Residents have recently been given a questionnaire to complete about their views. The Manager expressed that this still needs to be done with health and social care professionals, as this had not been done for some time. As identified earlier within the report residents are able to meet privately with an advocate from MHIST to discuss any areas they wish to, where necessary information would be shared with the Manager. Feedback continues to be sought from staff during the periodic team meetings and supervisions. Periodic safety checks are carried out as required. The home has recently had the 5-year electrical check, a copy of the certificate is to be forwarded to the CSCI once received. The Manager also explained that the equipment for the testing of small appliances was also being calibrated, once returned checks would be carried out. Staff also completed weekly health and safety checks within the environment and records are made. These include the recording of fridge, freezer and water temperatures. The Manager must ensure that the fridge temperature is monitored and where necessary adjusted so temperature is not too high. Further records for water temperatures should also identify which areas within the home have been checked. It was also noted that a fire drill has not been undertaken since January 2006, a further drill should be arranged. The Manager may wish for this to coincide with the new resident moving into the home. Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 23 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 3 X 2 X X 2 X Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 24 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 YA9 Regulation 13 Timescale for action That risk assessments are 30/09/06 reviewed with the care plans then signed, dated and amended where necessary. That on-going encouragement 30/09/06 and supported is provided ensuring service users effectively meet their personal care needs. That on-going work required in 30/09/06 relation to the environment is completed, as outlined within the report and that suitable hand washing facilities are made available within the laundry. That information required under 30/09/06 Regulation in relation to staff is held on file prior to commencing employment. (previous timescale of 3 March 2006) Refer to report. That training identified within the 30/10/06 report is provided ensuring that all staff have completed such courses. That an up to date fire drill is 30/09/06 undertaken involving all service users and staff, particularly those individuals who are new. That the record of water 30/09/06 temperatures identifies, which areas have been checked. DS0000009315.V297661.R01.S.doc Version 5.2 Page 25 Requirement 2. YA18 12 3. YA24 YA30 23 4. YA34 19 5. YA35 18 6. YA42 23 7. YA42 23 Hartington House 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 YA37 YA39 Good Practice Recommendations That a copy of the Manager NVQ level 4 certificate and on completion the RMA certificate are forwarded to the CSCI. That a report in respect of all quality reviews is written outlining the development plan for the home and made available to all interested parties. That a copy of the 5 year electrical certificate is forwarded to the CSCI. That the fridge temperatures are monitored and where necessary adjusted so that the temperature is not too high. 3. 4. YA42 YA42 Hartington House DS0000009315.V297661.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Hartington House DS0000009315.V297661.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. 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!