Inspection on 19/10/06 for Hawthorn Street

This inspection was carried out on 19th October 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hawthorn Street 01/02/06

Hawthorn Street 14/11/05

Hawthorn Street 30/03/05

Hawthorn Street 12/01/05

Hawthorn Street 29/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hawthorn Street 2-4 Hawthorn Street Amisfield Road Hipperholme Halifax West Yorkshire HX3 8NZ Lead Inspector Lynda Jones Unannounced Inspection 19th October 2006 10:30 Hawthorn Street DS0000001053.V317005.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 Hawthorn Street DS0000001053.V317005.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. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorn Street Address 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) 2-4 Hawthorn Street Amisfield Road Hipperholme Halifax West Yorkshire HX3 8NZ 01422 203541 www.st-annes.org.uk St Anne`s Community Services Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: Hawthorn Street is a care home that is registered to provide care and support for seven adults with physical and learning disabilities. The home is owned and managed by St Anne’s Community Services. The home is in the Hipperholme area of Halifax. Local shops, a church, pub and other local amenities are within walking distance. The home can be easily accessed by public transport. Accommodation is provided in two semi detached houses. There is internal access to both houses. Large living and dining areas are provided in each house. All of the bedrooms are single; toilet and bathing facilities are located close to the bedrooms. The houses are surrounded by well-maintained, enclosed gardens. Fees are £346 pw; this includes accommodation and all meals. People living at the home buy their own personal toiletries. Residents also make a weekly contribution for use of the homes transport. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgement categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This visit to the home took place over 5.5 hours. A pre inspection questionnaire was sent to the home before the visit took place. This provided useful information about Hawthorn Street, which has been used in the preparation of this report. Since the last inspection of the home, there has been a change of manager. The manager, who is not yet registered with the Commission for Social Care Inspection, only took up the post in July 2006. During the site visit, discussion took place with the manager and staff on duty. Records were looked at in the office and care practices were observed during the visit. A tour of the house took place. Comment cards were sent to relatives of residents asking for their views about the home. Three relatives provided their views on the home. Residents themselves are unable to complete comment cards because of the complex nature of their disabilities, although one person did fill one in with assistance from a family member. What the service does well: Visitors to the home say they are made to feel welcome when they call. The staff have a good understanding of the needs of all of the residents. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 6 The pen pictures on the personal plans are well written. Staff and residents get on well together. One person said, “Its nice living here” he said he “likes all of the staff”. Everyone goes out regularly and takes part in lots of different activities. The rotas are organised so that staff can support people on a one to one basis. Residents are supported to keep in touch with family and friends. There is plenty of variety on the menus. Staff are looking at ways of increasing the choices available to people. Staff receive appropriate training in adult protection awareness. What has improved since the last inspection? What they could do better: The licence agreements between St Anne’s and the men who live at the home need to be checked to make sure everyone has one and they are accurate. Overdue personal planning meetings need to take place. Staff must complete the objective charts on the personal plans, these charts allow progress towards personal goals to be monitored and provide evidence that staff are following what is in the plans. The records were not up to the standard found at the last inspection. The OK health checks need to be reviewed to make sure the information is up to date and that annual health checks are taking place. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 7 The house lacks a “homely” feel. The lounges are devoid of ornaments and pictures and they do not look particularly inviting. The decoration in these rooms requires attention. The sofa in the one of the lounges needs to be replaced with one that will withstand wear and tear. Several handles on the kitchen cupboards need to be repaired or replaced and the cooker in one of the kitchens needs to be checked to make sure it is safe. Some of the bedrooms need to be redecorated and personalised. The standard of record keeping has slipped over the period when there was no manager in post. The staff team now need to work together to get the service back on track. 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. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are provided with information about the home to help them decide if it can meet their needs. Licence agreements need to be reviewed to make sure that everyone has one and that they are accurate. EVIDENCE: Most of the men at Hawthorn Street have lived there since the home opened in 1993. The last person to move into the home did so in May 2005. His admission to the home was looked at as part of the inspection that took place in November 2005. At that inspection the homes admission procedures were found to be good, with all of the necessary assessment information being completed to make sure that the home could meet this persons needs. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 10 It is St Anne’s policy to provide everyone living at the home with a licence agreement outlining their terms and conditions of residence. The licence agreement for the last person to move in had not been completed, despite the fact that he moved in over a year ago. This needs to be actioned. On another licence agreement the accommodation charge was recorded as £390.96, this is more than the charge stated in the pre inspection questionnaire. The manager was unable to comment as both licence agreements related to the period before she worked at the home. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are conversant with what is in the personal plans; residents are supported and encouraged to be as independent as possible. All plans need to be reviewed and overdue planning meetings need to be set up. EVIDENCE: Everyone living at the home has an individual personal plan. The plans that were examined contained detailed information about how assessed needs should be met. Discussions with staff confirmed that they were familiar with the content of the plans. Every personal plan contains a good pen picture of each person, which gives details about the sort of life experiences people have had. The records include information about where people have lived, and about their families. There is information about what people like to eat, what they like to do with their time, individual hobbies and interests, and about the sort of things that people need help with. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 12 Work on the plans appears to have slipped recently. Some of the documents on individual files had not been signed and dated so it was not always possible to establish whether the information was current. From looking at the files, it was not easy to track the dates of the last planning meetings and service agreements and it appeared that in some cases, individual planning meetings were overdue. Discussions with the manager indicate that she has picked up on this issue and this is now in hand, systems are already in place to review all individual files and dates are being set for planning meetings. Staff at the home act as “keyworkers” for individual residents. Through staff supervision, the manager and deputy manager intend to work through the plans with individual members of the team to ensure that each one is accurate and up to date. From speaking to staff it is evident that they know residents very well, they get on well together and enjoy good relationships. There is evidence that people are offered opportunities to participate in the day to day running of the home and positively encouraged to develop their domestic skills. Residents are supported to make decisions about their lives and encouraged to be as independent as possible. Three relatives returned comment cards. Two said they were kept informed of important matters that affected their family member and they were consulted about their care. A third relative said they felt they were only consulted when they attended the annual personal planning meeting. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Everyone goes out regularly and takes part in a range of leisure activities. Staff are good at supporting people to stay in touch with their families. The menu is varied and records are kept of all meals provided. EVIDENCE: From discussion with staff, it is clear that individuals are encouraged and supported to pursue their own interests and hobbies. Staff report that everyone has a set amount of time allocated each week to take part in community based activities. Two people go out to college to do art and cookery classes, others enjoy swimming, walking and going to football matches. The records show that everyone has the opportunity to go to the cinema, theatre and to the pubs and Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 14 cafes in the area. The staff rotas are organised so that time is set aside to allow staff to work on a one to one basis with residents. Records relating to leisure activities are not always kept up to date and lack detail. On one file examined the record for week commencing 2/10/06 indicated that the resident had only been supported on one activity lasting 1.5 hours for the entire week. There is evidence that residents are supported to keep in contact with their family and friends. One person has an overnight stay with his mother each week; others are visited by their relatives. Relatives who completed comment cards said they were always made to feel welcome when they called and they confirmed that they could conduct their visits in private if they wished. Menus are prepared weekly, bearing in mind individual likes and dislikes. Menus that were examined showed that a varied menu is offered. Most people eat together and have the same evening meal; the manager said the team are considering ways of increasing the choice of meals available at teatime. At lunchtimes, the staff show people the alternatives that are available and everyone is encouraged to choose what they would like to eat. The staff try to encourage healthy eating. A record is kept of all the meals provided. When staff are not in the kitchen, the door is locked to prevent accidents occurring. During the course of the visit, staff frequently prepared drinks for everyone. Staff said residents who enjoy and benefit from doing the food shopping accompany them each week when they buy provisions for the house. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is delivered with discretion and residents are treated with dignity and respect. Assessments of healthcare needs must be updated. EVIDENCE: There was evidence in the records to show that staff support residents to attend healthcare appointments with GP, dentist and optician etc. An “OK health check” is completed in respect of each person in order to ensure that healthcare needs can be met. Some of this documentation was out of date, for example, it was not always possible to tell whether annual checks were up to date, the manager had already noted this and all OK health checks were being reviewed. Everyone is now booked for a medication review, the manager reported that these were also overdue. Staff had noted that one individual tended to isolate himself in his room. The plan included goals to encourage more interaction with others in the household and to encourage mobility. The rationale behind the goal was clear and well written. A member of the community rehabilitation team had carried out an assessment and had left details of some exercises that needed to be done Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 16 twice daily to promote mobility. An objective chart had been set up and each day staff were required to record whether the exercises had been done or not. Staff did not always complete the charts so it was impossible to measure the effectiveness of the exercises. On 28/9/06 when the page was complete, all recording on the chart stopped because no one had bothered to insert a new page. During the day the staff were observed supporting people with their personal needs in private and people were treated with dignity. The staff on duty said they encourage everyone to make choices about what they want to wear and they are encouraged to do as much as possible for themselves. The home uses a monitored dose system for the administration of medication. All staff who take responsibility for giving out medication have been trained to do so. Hawthorn Street DS0000001053.V317005.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): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are protected from abuse and have their rights protected. EVIDENCE: A detailed complaints procedure is in place. No complaints have been made. Two out of three relatives said they didn’t know about the procedure, all three said they had not needed to complain. One resident who completed a survey said he knew how to make a complaint and he knew who he would speak to if he was not happy. Staff have received adult protection awareness training, this was confirmed in the pre inspection information and by staff during the visit. St Anne’s training section provides regular training updates on this subject. From speaking to staff it is apparent that they are aware of their responsibilities in this area. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The décor throughout the home needs attention. The communal areas could be made to look more homely. EVIDENCE: A full tour of the home took place during the visit. Accommodation is provided in two adjoining houses, which are connected by a corridor enabling staff to move between the properties, although the houses function as two separate living units. Each side of the house has a lounge, dining and bathing facilities, all bedrooms are single. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 19 The lounge in number 2 is bare and uninviting, it has the appearance of a room that someone is either planning to move into or move out of. There are no pictures on the walls and few ornaments. The room felt cold and contained only one two seater sofa. Staff said the furniture in the house has to stand up to some heavy wear and tear, the other two-seater sofa had been broken and had to be thrown out but it hadn’t been replaced. A neighbour of a member of staff donated a chair, which was already looking very worn. Three men live in this part of the house. There is not enough furniture in the room to seat all of the men and the staff on duty. If the furniture does have to withstand heavy wear and tear something more suitable for purpose should be purchased. There is a tear in the carpet and the walls are marked at various points around the room. At some point in the past a TV cabinet has been removed from the wall, the wall has not been redecorated and the old wall covering is visible. The bath in this part of the house is very low. One of the men is quite tall and doesn’t find it easy to get in and out. The bathroom has not been altered since the house opened in 1993. In one room the wall behind the bed head is marked where the occupant rocks his head on the wall. This room needs a padded headboard fastened to the wall. There are no pictures on the wall and the room is not particularly personalised. All three bedrooms would benefit from redecoration but the manager said there is insufficient money in the budget for the home to do this. In one of the bedrooms a waste bin is used as a laundry basket, the manager said she did not know why this was happening. It should be replaced with something more appropriate. There are no plugs in the bedroom sinks. A member of staff said this was to prevent anyone putting the plug in and filling the sink to overflowing. No one could cite any instances of this ever happening and there were no risk assessments in place to indicate that this had been a problem. This must be risk assessed. The base of the chair at the bottom of the stairs in this part of the house is very worn and should be replaced. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 20 In the kitchen/dining room a new cooker has been purchased and a new fridge freezer is on order because the seal on the old one is damaged. Five of the handles on the kitchen units are damaged and staff said the cooker hood/extractor is not working. The varnish has worn off the dining tables and chairs that have been in use since 1993. In house number 4 the TV cabinet has also been removed from the lounge leaving the old wallpaper visible. There are areas around the curtain rails where some work has been done in the past, the walls haven’t been repainted and the bare plaster is exposed. This room does have two small, two seater sofas for the four men who live there. There is not much room, people have to sit very close together, and there is no extra room for staff. In the downstairs toilet the seal around the edge of the flooring is no longer effective and the floor is marked. In the dining kitchen, four drawer handles were broken. The markers on the temperature dials on the cooker have worn off, leaving no visible indication of the actual temperature, this needs to be checked to make sure it is safe to use. The floor covering is marked; staff say this is from cups and other objects being smashed on the floor. The dining table and chairs were inherited from another St Anne’s home some years ago when that home got some new furniture. In one bedroom, the carpet is very worn in front of the chair that the occupant likes to sit in. The chair is ripped, a drawer front is broken and a handle is missing off one of the drawers. All of the rooms would benefit from redecoration; some have not been redecorated since the men moved in. One person moved into a room with non-slip flooring that was put there to meet the needs of the previous occupant. This resident should have the option of having a carpet if it is practical and safe to have one. There was no evidence that the repairs and redecoration mentioned in this report had been identified and included in a planned maintenance and renewal programme for the home. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 21 The St Anne’s licence agreement clearly states that “St Anne’s agrees to keep in good repair and decorate when needed the communal areas, the outside of the property and your room”, it also says it will “keep in good repair and replace when needed the furnishings and fittings in the communal areas”. When all of the above points were raised with the manager she said there was insufficient money in the budget to address the issues. Residents should not need to pay for their rooms to be upgraded. On a more positive note, all of the carpets have been cleaned very recently and new net curtains have been purchased. There is a list of household jobs that need to be done each day to ensure that a good standard of hygiene is maintained. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to meet the needs of residents. All staff have completed the required mandatory training. EVIDENCE: Staff have completed essential training such as health and safety, food hygiene, fire safety, moving and handling, emergency aid and adult protection awareness. Some staff who were on duty had recently attended training in promoting diversity, equality and rights, which they said they enjoyed and found valuable. Monthly staff meetings are held at the home. An away-day for all of the team is scheduled for November when they plan to discuss risk assessments and behavioural guidelines. The manager and deputy manager have recently completed a two-day appraisal and supervision course and they plan to divide staff supervision between them. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 23 The home is adequately staffed to meet the needs of residents. Although there are some staff shortages at the present time due to long term sickness, the staff on duty said all shortfalls on the rota were covered either by members of the team covering additional hours or by agency or St Anne’s bank staff. The same agency staff and bank staff tend to work at the home, as they know the residents well and they can provide support with some continuity. New staff have recently been recruited and are awaiting Criminal Records Bureau checks before they can start work at the home. The Provider Relationship Manager for the Commission for Social Care Inspection examined a sample of St Anne’s staff files in April 2006. Recruitment practices were generally found to be good, with references and Criminal Records Bureau checks taken up before new staff start work. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of record keeping has slipped over the period when there was no manager in post. The staff team now need to work together to get the service back on track. EVIDENCE: The service manager carries out regulation 26 visits to the home every month and reports on the conduct of the home. Written reports of these visits are available at Hawthorn Street and copies are sent to the Commission for Social Care Inspection. When the manager first took up post the service manager visited weekly and provided the manager with valuable support. She provides the manager with regular monthly supervision. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 25 The manager of the home is not yet registered with the Commission for Social Care Inspection in respect of Sutherland Court. She is in the process of making an application for registration. She is skilled and experienced in this area of work. The home will benefit from a settled period of management; the standard of record keeping in some areas has slipped over recent months. Checks show that records are generally up to date although some gaps are found in recording and entries are not always clear. The service has a comprehensive set of policies and procedures, which are reviewed regularly. Details of implementation and review dates were provided with the pre inspection questionnaire. Health and safety issues at the home are monitored regularly. Fire alarms and emergency lighting is tested weekly and a fire drill and fire safety training has taken place within the past six months. Relatives and other representatives of residents are consulted about the way the home is run. “Satisfaction Surveys” were recently sent out to relatives, four responses had been received up to this visit taking place but the results had not been collated. Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 26 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 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 2 28 2 29 2 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 3 X X 3 X Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 27 NO 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 2 Standard YA5 YA6 Regulation 5 15 Requirement Everyone living at the home must be issued with a licence agreement/contract. Personal plans must be kept under review and updated to reflect any changes in individual needs All OK health checks must be reviewed and updated to ensure that individual needs are identified. An audit of the house must be carried out to identify the areas where repair and redecoration is required. All identified areas need to be included in the maintenance and renewal programme for the home, together with timescales for carrying out the work. A copy of this programme must be forwarded to the Commission for Social Care Inspection. The cooker needs to be checked to make sure it is safe for staff to use. The manager must make an application to Commission for Social Care Inspection for registration DS0000001053.V317005.R01.S.doc Timescale for action 01/12/06 01/12/06 3 YA19 12 01/12/06 4 YA24 23 31/12/06 5 6 YA24 YA37 12 8 17/11/06 01/12/06 Hawthorn Street Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Hawthorn Street DS0000001053.V317005.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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