CARE HOME ADULTS 18-65
Hulme Hall Close Hulme Hall Road Cheadle Hulme Stockport Cheshire SK8 6JZ Lead Inspector
Jackie Kelly Unannounced Inspection 12th July 2006 10:00 Hulme Hall Close DS0000034392.V307435.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 Hulme Hall Close DS0000034392.V307435.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. Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Hulme Hall Close Address Hulme Hall Road Cheadle Hulme Stockport Cheshire SK8 6JZ 0161 486 9783 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) Stockport MBC Adult and Community Directorate Lance Tipper Care Home 15 Category(ies) of Learning disability (15), Physical disability (3), registration, with number Sensory impairment (1) of places Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A manager, working a minimum of 30 hours each week, must be in place at all times who has the qualifications, skills and experience necessary for managing the home and who is registered with the Commission for Social Care Inspection. No more than two places can be used as respite/emergency/short term placements. 12/01/06 2. Date of last inspection Brief Description of the Service: Hulme Hall Close is owned by Stockport Metropolitan Borough Council and is registered for 15 young people who have a learning difficulty. However the current number of residents living at the home was 10. The home is part of Stockport Learning Disability Partnership, Adults and Communities Directorate. The responsible person for Hulme Hall Close is Mrs M Wilson (Assistant Director Adults and Communities Directorate) with Mr Lance Tipper the Registered Manager. The home is divided into separate units, which are interconnecting on the ground floor only. To access the first floor, the young people must be able to climb the stairs apart from one unit that has had a stair lift fitted. None of the single rooms, (which are below the National Minimum Standard of 10sq.m or 12sq.m for those service users who use a wheelchair), had an ensuite facility. The home had a large garden to the rear of the building and hard standing to the front, which can accommodate a reasonable number of cars. The home is located in the Cheadle Hulme area of Stockport. Apart from the local pub/restaurant; the shops and other amenities are not accessible other than by car. Public transport is also not readily available. The current rate at the time of the inspection was £737.10 per week with the residents contributing £61.75. Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over two half days. On the first day the inspector spent time talking with the manager Mr Lance Tipper and one of the 1st line managers. Care plans, and personal support plans were looked at. The inspector also discussed the requirements and recommendations of the previous report of January 2006. The second visit took place the next day in the evening when both the 1st line managers were present. Time was spent talking with the managers and a support worker; other support workers and residents were present during a brief tour of the home. Due to the residents limited communication skills and understanding it was not possible for the inspector to have any meaningful discussion with them. However the residents were appropriately dressed and looked cared for. No one had been admitted or discharged from the home for a number of years. Also no new staff had been appointed since the last inspection of January 2006. The minimum number of staff hours, which were required for the current group of service users using the Department of Health Guidelines, is 795.98. Survey forms were sent to four relatives. Three had been returned at the time of writing this report. All said that they were happy with the care the residents received. A comment card was sent to the General Practitioner, which was returned; there were no concerns reported and they were satisfied with the overall care provided within the home. There had been two complaints and three adult protection allegations. One of the complaints and two of the adult protection allegations were still ongoing. Whilst the senior managers had for the most part followed correct procedures for reporting and investigating the complaints/allegations concerns must be raised as to why these incidents occurred and what could have been done and what must be done in the future to prevent them happening. Four of the six requirements and all of the recommendations from the previous inspection report of January 2006 had been implemented. The two outstanding requirements have been included again in this report together with 7 new requirements and 5 new recommendations. What the service does well:
The home was clean and free from any offensive odours and was reasonably decorated and furnished.
Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 6 Supervision and staff meetings took place on a regular basis and were recorded. These were particularly important to pass on information to support workers, to obtain their views and opinions, to assess their quality of work and to look at training needs. The health needs of the residents were well served through the consultant in learning disabilities who the residents visited on a regular basis to monitor their progress. The support workers helped the residents to access activities whenever they could. One resident had recently gone to visit relatives which was a great achievement. There was a varied training programme in place for support workers to access. Many of the support workers had completed a National Vocational Qualification Level 2 and/or Level 3. All the residents had a ‘pen picture’ on the care plan, which was good and informative. All the three relatives who completed a survey form said that they always felt welcomed by the staff team. What has improved since the last inspection?
The statement of purpose had been produced in a format, which was suitable for the residents. Copies had been placed in the residents’ files with a copy sent to relatives. The result of this was that people had information about the service being offered. A number of policies and procedures had been produced in a format that was more suitable for service users who may be able to understand the contents and how they affect them. The application form had been amended to ask for full employment history to ensure that only suitable people were employed. One-day courses on infection control had taken place which a small number of support workers had attended. Further training in the form of a distancelearning package was to be introduced. The manager was now registered with the Commission for Social Care Inspection, which is a legal requirement. One of the 1st line managers was taking a National Vocational Qualification Level 4 in Management. Other improvements, which had taken place, included the re-decoration of one of the flats earlier in the year, which included lounge, corridor and bedrooms.
Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 7 Almost all of the residents had received an assessment/review with most of them having been written up. These reviews should give an up-to-date picture of the residents’ needs and requirements to allow the support workers to provide appropriate care. All of the residents now had a personal support plan, which gave easily accessible information to support workers and relatives/representatives. A staff development officer had been appointed specifically for implementing training for those support workers who care for people who had a learning disability. This should prove beneficial as a training programme can be developed through discussion with the relevant staff to meet the needs of the workforce to help them provide a better service to the residents. What they could do better:
Annual staff appraisals (this was also a requirement in the September 2005 and January 2006 report) had not been implemented. The manager said that these could be introduced from September 2006. It is essential that all support workers have an annual appraisal to ensure that their training and development needs are being recognised and met. A training matrix should be devised to enable easy access to what training each individual member of staff has done and what they need to update etc. A copy should be displayed at the home and a copy sent to the Commission for Social Care Inspection. The management of Hulme Hall Close are legally bound to produce an annual development plan and quality assurance report with copies sent to the Commission for Social Care Inspection and made available to residents and relatives/representatives. This had not been done within the timescale of 1 May 2006. The purpose of this report is to provide information to the Commission, relatives, and other interested parties, which proves that the management team is looking at what the service provides and how it is provided and what changes can be made to improve the service further. The personal support plans that had been introduced were good however some amendments needed to be implemented alongside the main care file to improve the system further. This would allow easier access to current information and care needs of the service users. Personal support plans should be kept in an individual file in the interests of confidentiality. Also the daily record should be kept with the personal support plan. Any charts used for recording specific details must be in a printed format and completed in a professional manner for the information to be transferred into appropriate ways of managing the care needs of the resident. The service must look at ways of improving the resident’s quality of life in accessing suitable activities, which the residents enjoy. No resident must be left without any service due him or her not having enough income to pay for a private agency to provide day support.
Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 8 There were concerns that not all of the residents were being respected in the way that they should. Whilst this was being investigated it is important that the home does not await the outcome of these investigations but puts in place measures to monitor the quality of care and implement any training, supervision, staff meetings necessary to ensure that the residents health and safety is being respected and provided for. The current system of approving risk assessment should be looked at in order to ensure that they are available to support workers with the minimum amount of delay in order that the residents’ health and safety is being maintained. The information obtained regarding the residents current needs and requirements from the recent assessments/reviews that had taken place must be incorporated in the daily personal support plans/care plans as soon as possible. Delay in transferring this information into daily routines could be denying the residents appropriate care to enhance their quality of life. Monthly unannounced monitoring visits by a representative of the organisation must be take place and a report written which is sent to the Commission for Social Care Inspection. No visit had been made since May 2006. These must be restarted in order to ensure that the residents’ health and personal care needs and regulations are being met. 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. Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 9 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 Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 10 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): 1&2 Quality in this outcome area is good. Information was available to the residents and relatives in a suitable format, to help them make choices and be aware of what the service offered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A combined statement of purpose and resident guide had been produced in a user-friendly format and distributed to all relatives and representatives. A copy was also placed on the residents file. There had been no new residents admitted or referred to the home since the previous inspection of September 2005. Many of the residents had been living at the home for a number of years. However documentation and procedures were in place to undertake assessments prior to admission should there be any referrals. Evidence of these documents was seen on existing residents files. Hulme Hall Close DS0000034392.V307435.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area was adequate. The care plans for the most part reflected the residents’ needs and requirements to enable them to lead as independent life as their capabilities would allow. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All but two of the ten residents had received an assessment/review, which involved the resident, relative, consultant and Hulme Hall staff. The remaining two review meetings were scheduled to take place over the next few weeks. The majority of reviews had been written up but the notes had not yet been included on the residents’ files or the recommendations reflected in their care plans. It was not acceptable for two residents’ notes to be kept together in the personal support plan (‘easy access file’). This practice contravened confidentiality and did not comply with data protection guidance. The daily records were kept separate from the personal support plan. This meant that there were three files for each person. It is recommended that the resident’s personal support plan and daily record should be kept together in one file for
Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 12 that resident. This reduces the number of files to two; one care file (main record) and one personal support plan (the daily working file or ‘easy access file’) which contains information about current daily living/care needs, appointments, weekly activities and immediate requirements. The personal support plans were good. However all information should be completed and there should be no gaps. If the requested information does not apply it should say so. The main care files were for the most part satisfactory and contained a ‘pen picture’ of the resident, which was informative and would be useful for any new support worker. It is recommended that this ‘pen picture’ be put in the personal support file (daily working file) rather than kept in the main file. There was duplication of information within the care file and the personal support plan, which could lead to confusion as to what the current situation was. Any out of date information must be removed and archived. A support worker commented that there were problems with the risk assessments being updated. This may be due to the system currently in operation whereby the risk assessments had to be approved by a senior manager before being placed on the residents file. The support workers were keeping a record of one resident’s behaviour patterns and one resident’s food intake. An appropriate format, which was more professional for recording behaviour patterns, needed to be implemented. The daily food intake chart required more information when the resident refused to eat such as; if he was offered an alternative. Policies and procedures that were relevant to the residents were now available in a user-friendly format. Hulme Hall Close DS0000034392.V307435.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is adequate. There had been no improvement to the resident’s access to, developing skills, community/leisure facilities. Family contact was being maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No one within the current group of residents had the ability to take part in either paid or voluntary employment. The home is situated in an area of Cheadle Hulme which has no shops, or public transport close by. However all the residents have access to a car which had been purchased by the individual residents under the mobility scheme. There were five cars; one for each flat. All the residents required assistance to access community services. Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 14 Much of the service provided was no different from that which was in place at the previous inspections in September 2005 and January 2006. The amount of day service and activities attended differed between residents. Activities, which took place, included shopping, attending Offerton resource centre and hydrotherapy pool, meals out, disco, bike rides and visits home to relatives. The first line managers were expected to provide cover in a flat whilst the support worker accompanied a resident to an activity. There was no funding available in the overall budget to provide a day service for the residents. One resident (through relatives) had accessed a voluntary organisation to provide support one day a week to accompany him on his bike rides. The resident was paying for this privately. This type of service was being looked at for other residents however this may not be a viable option for some residents who may not have the income to support this. The resident’s circle was still restricted to family, support workers and carers. A small number of the residents regularly attended a disco night or day service, which had extended their circle of acquaintances albeit with people with a similar disability. Superficial acquaintances were made in the community through visiting the cinema, pub, shopping etc. Each unit planned the menus and shopped accordingly. The senior staff said at previous inspections that the support workers did prepare food and did not rely on ready cooked meals. Hulme Hall Close DS0000034392.V307435.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area was adequate. The service provided each resident with access to health care services. However not all the residents had their rights respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 16 Information received from the three relative comment cards that were returned to the Commission said that they were happy with the care their relative was receiving. The inspector observed that the residents who were seen during the inspection were dressed appropriately and no unacceptable practices were observed. The inspector had received information, which gave concern that not all the residents’ rights were being respected. These issues were being dealt with by the service as part of the ongoing complaint and adult protection investigations. Visits by the residents to the consultant for learning disabilities (who was also involved in the current review process) for regular check ups were in place. The local health centre was being used for the residents’ day-to-day needs. A comment card was sent to the GP who did not express any concerns. The implementation of the ‘Health Action Plan’ was on hold whilst the reviews/assessments and new resident plans were being introduced. Other services had been obtained, such as dentist and opticians as was necessary. None of the residents were capable of managing their own medication. All the support workers had received training on safe handling of medicines. Hulme Hall Close DS0000034392.V307435.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. There are concerns that the residents are not being fully protected in all areas of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There had been two formal complaints made to the Stockport Learning Disability Partnership by relatives. One had been dealt with but the second was ongoing. Recent allegations of abuse were in the process of being investigated at the time of the inspection. The inspector had concerns regarding the safety and protection of residents within one of the flats. The Commission had received a letter from the relative of the resident regarding the allegation of abuse and the way in which the investigation into the allegation had been conducted. There was a policy and procedure in place and a ‘rolling programme’ for training the staff on the protection of vulnerable adults. All relatives had been invited to the recent reviews/assessments, where people were able to express their views and opinions. Hulme Hall Close DS0000034392.V307435.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is adequate. All furnishings, fittings and equipment were in a reasonable condition and suitable for the needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home did not meet the national minimum standard of 10sq.m with regard to bedroom sizes. However those care homes that did not provide this amount of space before the 1st April 2002 was able to continue using these rooms. The room sizes were defined in the statement of purpose and resident guide. The inspector looked at three of the flat’s communal areas, which were satisfactory. Flat 4 had at the beginning of 2006 had the lounge, corridor and two bedrooms decorated. The manager said that a distance learning package for training support workers on the control of infection was being looked at. The 1st line manager said that a small number of support workers had attended a one-day course. Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 19 The home was not within easy reach of public transport or shops. A pub/restaurant was near by. The home was clean and free from offensive odours. Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35 Quality in this outcome area is adequate. The training and supervision was for the most part meeting the needs of the support workers. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No new staff had been employed at the home since the last inspection of January 2006 with the majority of the support workers having been employed at Hulme Hall close for many years. The application form that was used by Stockport Adult and Community Services Directorate had been amended to include a statement asking for full employment history from leaving school or full time education. The staff development division of Stockport Adult and Communities Directorate had recently appointed a staff development officer specifically to implement training for support workers who care for people with a learning disability. Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 21 A number of the support workers were registered for the Learning Disability Award Framework (LDAF) training. The majority had a National Vocational Qualification (NVQ) Level 2 with a number having a Level 3 One of the 1st line managers had started taking a NVQ Level 4 in Management. It was recommended that a training matrix be devised with a copy sent to the inspector. An enlarged copy displayed will allow senior management easy access to information as to what training people had done and what they needed to do. An annual appraisal for each member of staff, which takes account of their development needs, had not been introduced. This was a requirement in January 2006 report with a timescale of 31/03/06. Supervision was in place and was confirmed by staff members. The home had recently acquired administrative support, which had improved recordings etc. However the administrator only works part time, which limits the amount of work that can be undertaken. The number of staff hours that are required for the current group of residents using the Department of Health guidelines is 795.98. The senior managers must ensure that this number of hours is in place at all times. Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. For the most part the home was run (within budget constraints) for the residents by a staff team who were, experienced and aware of the health and safety needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager who was employed at Hulme Hall Close was registered with the Commission for Social Care Inspection and had the necessary experience and qualifications. The monthly meeting, which had been implemented and reported on at the previous inspection, had been replaced with daily reports between senior staff and support workers. The manager felt that this was more beneficial in keeping both parties informed of immediate needs of the residents. Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 23 A small number of support workers had attended the basic food hygiene course. Regulation 26 states that a representative of the organisation must make an unannounced visit to the home at least once a month and produce a report, which must be sent to the Commission for Social Care Inspection. The last monitoring visit and report received was May 2006. This was not acceptable. The monthly monitoring visits must be re-started maintained with copies of the reports being sent to the Commission. The manager had taken part in a Quality Assurance Review of Hulme Hall Close with other senior managers. A copy of the outcome of the review had been given to the inspector. A quality assurance report and annual development plan would be implemented from this review. This was a requirement under Regulation 24 of the Care Homes Regulations 2001 in the previous report of January 2006 with timescale of May 2006, which had not been met and is included again in this report. Senior managers should be aware that Regulation 24 has been amended and took effect from July 2006. When producing the required report as stated above the new regulations must be considered. The report must be submitted to the Commission within one month of its request; that is this timescale given under the requirements section. Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 X LIFESTYLES Standard No Score 11 x 12 N/A 13 2 14 X 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 3 x Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (2c) Requirement The registered person must begin to amend the care plans (where necessary) to reflect the identified needs of the residents from the recent assessments/reviews. The registered person must ensure that any additions to the care plan such as behaviour charts are presented and completed in a professional manner. The registered person must look at ways of improving the residents’ quality of life through accessing activities and community facilities, which will not be restricted through lack of individual funds. The registered person must put in place measures to ensure that the residents right to be respected at all times is maintained by all support workers. The registered person must assess the adult protection investigations and act on the information received to ensure the health and safety of the
DS0000034392.V307435.R01.S.doc Timescale for action 30/11/06 2. YA6 12 30/09/06 3. YA13 16 (m) 30/11/06 4. YA18 12 30/11/06 5. YA23 13 (6) 30/11/06 Hulme Hall Close Version 5.2 Page 26 residents is maintained. 6. YA33 18 The registered person must ensure that the required number of staff hours (795.98), which is necessary for the current group of residents, is in place. The registered person must ensure that all staff receives an annual appraisal. Timescale of 31/03/06 not met. The registered person must produce an annual development plan, which is specific to Hulme Hall Close, which is part of the Quality Assurance report that must be sent to the Commission for Social Care Inspection and made available to the residents or their relatives/advocates. The amended regulations to regulation 24, which came into force on July 2006, should be accessed and incorporated in the report. Timescale (for the original requirement) of 01/05/06 not met. The registered person must ensure that the unannounced visits required under regulation 26 take place monthly and copies of the reports are sent to the Commission for Social Care inspection. 30/11/06 7. YA36 18 30/09/06 8. YA39 24 30/09/06 9. YA39 26 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA6 Good Practice Recommendations The registered person should collate the personal support plan and daily record together in one file. The registered person should ensure that there are no
DS0000034392.V307435.R01.S.doc Version 5.2 Page 27 Hulme Hall Close 3. 4. YA6 YA9 5. YA35 gaps in the information required on the personal support plan. The registered person should ensure that information is up to date in the main care plan and does not duplicate the information in the personal support plan. The registered person should ensure that the updating of risk assessments is done and approved as quickly as possible to ensure the safety and wellbeing of the residents. The registered person should produce a training matrix to maintain an easily accessible record of all training that support workers have taken. A copy should be sent to the Commission for Social Care Inspection. Hulme Hall Close DS0000034392.V307435.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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