Inspection on 25/01/06 for Iona

This inspection was carried out on 25th January 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Iona 26/02/10

Iona 11/08/09

Iona 14/09/07

Iona 07/06/06

Iona 25/07/05

Iona 02/03/05

Iona 03/08/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Iona 104 Well Street Biddulph Stoke On Trent Staffordshire ST8 6EZ Lead Inspector Peter Dawson Announced Inspection 25th January 2006 09:00 Iona DS0000004962.V274999.R01.S.doc Version 5.1 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 Iona DS0000004962.V274999.R01.S.doc Version 5.1 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. Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Iona Address 104 Well Street Biddulph Stoke On Trent Staffordshire ST8 6EZ 01782 523396 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) Mr Alan James Stockdale Mrs Jill Stockdale Mrs Wendy Scully Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Iona is a care home for younger adults providing personal care and accommodation for six people with a learning disability. One place can be used to provide a service for someone with mental health needs (Mental disorder).The home is situated close to local amenities very close to Biddulph town centre. There are good public transport links to the home. The building is an older type semi-detached house with adequate secluded garden area with lawn and patio. There is one single ground floor bedroom with shower cubicle, further 3 bedrooms on the first floor - 2 double and one single room which has en-suite facility. There is a bathroom on the first floor. The communal rooms provide adequate lounge and dining space. The main lounge is of good size and comfortably furnished, the dining area is little used since the kitchen was refitted which is the preferred dining area for residents. The former dining area is little used being used for activities or visitor use. The home is run on ordinary life principles where residents are supported as needed but are encouraged to maximise their potential with assistance from a professional and caring staff team. Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of this announced inspection the maximum number of residents (6) were living in the home. – There have been no new admissions to the home in the past 2-3 years. All residents were spoken to separately and together as a group. The residents in this home are comfortable with inspections and as usual made a positive contribution to the inspection process. The staffing group has totally changed in the past year. The Registered Manager left the home on 23rd December last – the home is managed in the interim period by the proprietor. Residents spoke very positively about new staff and had clearly forged new relationships with them. One resident did say he misses the Registered Manager. Residents spoke positively about their daily routines. There was initially one member of staff on duty until 10 a.m. who was busy making the necessary arrangements for residents to prepare to go on external visits. This provided the opportunity for the inspector to spend time in a relaxed way talking to the small group in the lounge areas. Several resident showed their bedrooms also with enthusiasm, generally stating they were happy with their surroundings including the communal areas. All areas of the environment were inspected and records relating to the inspection seen, including: care plans, risk assessments, fire records, staffing records, residents financial records and other general inspection information. No visitors were seen during the inspection, although two feedback cards were received directly by the Commission prior to the inspection from relatives. Both indicated they were satisfied with the overall care provided. One commented “staff turnover seems excessive at the moment”. Both said that they did not have access to inspection reports. There are concerns about the management of some areas of the home which are included in the body of this report. Improvements in these areas are required to be made. Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: A shared bedroom recently redecorated must be suitably equipped and “softened” to present a more homely, comfortable and personalised appearance. There are continence management needs of residents, but there were unpleasant odours relating to the management of those needs in several parts of the home. These must be addressed and resolved. The electrical socked in the kitchen area must be fixed to the wall to ensure resident safety. The personal expenditure of resident attending college must be reviewed. The staffing levels in the home are at the minimum levels with increased dependency levels too. Most staff are new and training needs are identified. Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 7 The home must review the staffing levels of the home again and provide a written report to the Commission by 31/03/06. Statutory staff training in first-aid is required for all staff. All staff administering medication must receive accredited training. The care planning system and information is inadequate. All care plans must be updated, re-written and reviewed on a regular basis. All risk assessments relating to resident activity must similarly be updated, rewritten and reviewed. Two written references must be obtained prior to employment and any criminal offences investigated. 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. Iona DS0000004962.V274999.R01.S.doc Version 5.1 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 Iona DS0000004962.V274999.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards relating to Choice of Home were not inspected on this visit. This is a static resident group and there have been no admissions to the home for the past 2-3 years. EVIDENCE: Iona DS0000004962.V274999.R01.S.doc Version 5.1 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 – 10 Care plans and risk assessments are dated and inadequate and all must be updated and re-written. There must be regular reviews on at least a 6 monthly basis. There was evidence that residents were consulted in matters affecting their lives and making daily decisions and choices. Other aspects of standard 8 could be improved. Information concerning residents was secure and confidential. EVIDENCE: Assessed and changing needs and personal goals are not reflected in their individual plan as required in this standard. Care plans sampled and discussions with the proprietor indicated that care plans had not been updated for sometime to reflect current need and therefore not reviewed on a regular basis. Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 11 Information was in several places and needs to be centralised to provide a working plan of care easily identifiable and concise. It is a requirement of this report that all care plans are re-written and comply with the standard. Daily notes are completed for all residents at least one and often twice per day. These records were satisfactory with an exception discussed with the proprietor concerning negative comments which had been recorded. She will pursue this matter with staff. A resident had been previously reviewed and additional funding made available by the sponsoring Local Authority to attend specific daytime activities. Another resident with complex and changing physical and psychological needs has been under review for re-assessment of needs since early 2005. There has been input from GP, Consultant Psychiatrist, CPN and other professionals. This has still not been concluded. Information in relation to this person was dated, with inaccurate risk assessments and information required by Behavioural Services specialists to monitor behaviour was incomplete. This matter is now being addressed by the Proprietor who is presently managing the home until in the interim period. There have generally been reviews on a 12 monthly basis for residents, but the requirement for at least 6 monthly reviews re-enforced with the proprietor as defined in standard 6.10. Risk assessments were dated and inaccurate. It is a requirement of this report that risk assessments in relation to all resident activity are reviewed and updated and reviewed thereafter on a regular basis. There was evidence in discussions with residents that they were consulted in the home about matters affecting their daily lives. This included daily routines, food choice, redecoration of bedrooms etc. Regular residents meetings were previously held but the last meeting was July 2005. The proprietor intends to arrange regular meetings with residents with the possibility of an external chairperson. Residents are not involved in policy reviews, joint staff meetings, or service user questionnaires provided by the home. This is an area that can be developed. There were indications that confidentiality in relation to records and information were in place. Iona DS0000004962.V274999.R01.S.doc Version 5.1 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): 11 – 17 The home positively strive to provide individual activities for personal development. Social inclusion and development of social skills are reflected in engaging residents where possible in the local community as part of normalisation and skill enhancement. Risk assessments must reflect balanced risks. Financing of transport by a resident must be reviewed. Food provision is good and residents express satisfaction. EVIDENCE: There are a range of educational, social and recreational activities which are accessed outside the home for residents. Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 13 Two people go to college regularly, two access day services unit at Kidsgrove. A resident attends regular, garden-based project in Leek run by the Rethink Organisation – additional funding is provided for this purpose. Two older residents who prefer not to attend external day centres are provided with a programme of external visits – shopping, outings, eating out etc. One goes each day to local shop alone (risk assessment must review this). The usual range of indoor activities are provided in the home on an ad-hoc basis to meet resident need and choice. There are visits to local places of interest and to pubs, bowling, theatre and restaurants. Two resident attending college course are taken by taxi and return by public transport as part of social development. One has ‘bus pass the other personally pays for the transport. This will be investigated by the proprietor. All residents have an annual holiday and generally residents have 2 holidays of approximately 5 days. Residents have preferred to go on holiday together rather than in smaller groups, this is being further discussed with residents at this time to ensure it is their continued preference. A resident spent 1 week in Egypt with relatives in December. The home have a 7-seater people carrier used for outings and staff cars are used as back-up for larger events. Transport is readily available to all for external visits. A resident goes assists in the Red Cross shop in Biddulph two days per week and enjoys her work there. She has attended for several years, has made positive relationships there and vastly increased her confidence/self-esteem. Relatives/friends are welcomed into the home and many residents go out with relatives for the day. Relatives/friends are seen as part of the social care needs of residents and contacts promoted and supported by staff. All residents spoken to were satisfied with the food provided. Weekly menus are chosen with resident input and subsequent shopping trips. Some are able to prepare drinks, snacks and assist with some food preparation – there are varying degrees of competence and safety – one resident competently prepared his sandwiches to take on his external placement. Risk assessments must be reviewed and updated to reflect the various skill levels in this area and programmes for involvement in food preparation established as part of personal development. Some residents have a need and wish to follow a healthy eating pattern/weight loss - staff assist and support residents in this. Iona DS0000004962.V274999.R01.S.doc Version 5.1 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 - 20 There was evidence to support the view that personal support is given applying the principles of care. Although awareness of health care issues were evident, recording of health care needs must be accurate, updated and reviewed. Recording of medication was good and accurate but accredited training in medication administration must be provided for all staff. EVIDENCE: The majority of residents required only oversight for personal needs e.g. personal hygiene. Others need more specific involvement to ensure good hygiene standards. Three require continence management support including one incontinent of faeces and two incontinent of urine. Clear routines exist to provide this aspect of personal care which is given respecting the principles of care. One resident requires oversight to dress, choosing clothes etc. All require assistance with bathing to ensure safety. Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 15 Early morning routines were seen to include demands for several residents in terms of rising, dressing, washing, bathing, eating etc. with timescales to be met for residents to attend external venus. This is a peak time of care need and clearly the person on duty is very busy. Needs were seen to be met in a competent and relaxed way. Key workers have recently been allocated to all residents. Two residents have been admitted to hospital in the past 6 months and received ongoing care in the home from the nursing service following discharge. Nurses have now completed their work and not required to attend. Health care records, as part of care planning information must be updated and reviewed regularly with a clear plan of care for health care needs and interventions. As mentioned previously there is an ongoing lengthy review of a resident who has mental health needs with a range of health care professionals involved. The close monitoring of changes in behaviour and health are required to be recorded for health care personnel and these have not always been completed satisfactorily. The proprietor is currently in the process of trying to complete documentation relating to changes in physical and psychological need. The care plan must be revised to reflect those changes. Health care services are accessed in the community. The GP surgery/Health Centre is directly opposite the home. Residents attend as required and access the usual routine screening clinics at the Health Centre. Very positive written feedback was received directly by the Commission from a GP indicating residents were brought regularly for checks, problems in relation to medication notified and the GP was satisfied with the care provided at Iona and the good communication with the home. The home report optical and dental services are accessed in the community as required. Two residents wear glasses and have checks at 2 yearly intervals. The inspector felt that this should be an annual check. None of the residents have diabetes. Medication is provided in MDS (blister packs) from the local Coop Pharmacy and good service reported. The pharmacy check the system in the home on a regular basis. Records relating to storage, administration and disposal of medication were seen. There were no omissions and records were clear and accurate. All medication returned to the pharmacy is recorded and countersigned by the pharmacy. Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 16 All staff administer medication as there is predominantly one person on duty throughout the 24 hour period. Some have received accredited training but several new staff have not and it is a requirement of this report that all staff administering medication must have accredited training. Iona DS0000004962.V274999.R01.S.doc Version 5.1 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): Standards relating to Concerns, Complaints and Protection were not inspected on this visit. EVIDENCE: Iona DS0000004962.V274999.R01.S.doc Version 5.1 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 Many areas of the home present a comfortable homely environment. The shared bedroom identified does not and must be personalised and equipped to provide a less austere appearance. The mal-odour identified in several areas must be addressed and resolved. The twin electrical socket in the kitchen area must be made safe. The building is generally well maintained EVIDENCE: The home is clean and comfortable. The lounge area is very comfortable and furnished along domestic lines providing good light and adequate space. The former dining area is presently unused, following decision by the residents to eat in the refurbished kitchen area. There are plans to provide additional furniture/equipment to encourage residents to use the former dining area as a sitting area. Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 19 A twin electrical socket in the kitchen area must be fixed to the wall and made secure to ensure safety for residents who regularly use the kitchen. There is one single bedroom with shower on the ground floor and two single and two shared bedrooms on the first floor. There is a toilet area on the ground floor and bathroom with toilet on the first floor. A requirement of the last report to provide new carpet in one shared bedroom has been completed. The other shared bedroom has been repainted and has vinyl floor-covering to assist continence management. – This room had a strong mal-odour which was also present in the reception and lounge areas. A requirement is made that the home must be kept free from offensive odours. Continence management should be reviewed and the means of routines to minimise odours. This shared room was stark and quite bare. The walls painted single colour. There are 2 single beds (no privacy curtain) 2 wardrobes, chest of drawers and each resident had portable TV which residents said they used. There were no chairs. There was no personalisation whatsoever, no photographs or personal effects nothing that indicated the individuality of the residents. This must be addressed with efforts to “soften” the room and make it more comfortable, homely and appealing. Other bedrooms in contrast were well personalised, comfortable and had a homely feel to them. The bathroom area is satisfactory and bathing aids are not required. There are sufficient toilets available. The proprietor is considering installation of a shower area to provide an alternative bathing choice. Adaptations are not required in the home at this time. The home is not identifiable as a care home in the community. It has a small garden area at the front and excellent patio area at the side with good seating etc. and used consistently throughout the summer months. Two further double-glazed windows have been installed recently with a programme to replace all in the future. A new toilet has been installed and the room redecorated. There has been some redecoration of bedrooms some months ago. Iona DS0000004962.V274999.R01.S.doc Version 5.1 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): 31 - 35 The staffing levels are at the minimum required level and must be reviewed. There has been complete change of staff in past year all posts are now filled but a programme of swift staff training is required to ensure a qualified, effective staff team. Staff are enthusiastic and want to be involved in training. The National Minimum standards relating to staffing cannot be met at this time. Good engagement between residents and staff were evident in the home EVIDENCE: This is a small home providing care for 6 residents with a mild learning disability. Waking night staff are not required but a member of staff sleeps in at all times and is on call. The remaining day staffing hours to provide one person on duty at all times is 98 hours per week. Staffing levels in the home have been questioned. A requirement was made in March 2005 for the staffing hours to be reviewed. The proprietor felt the number of staffing hours was adequate. Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 21 The situation in the home has changed recently – the Registered Manager left in December 2005. The proprietor who was previously the Registered Manager is now managing the home until a suitable Manager is found. At the time of the last inspection the weekly staffing hours were 126 which included 40 hours worked by the then Manager of which half were management and not care hours. This meant that the number of care staffing hours were 106 per week. They were considered to be the basic minimum required for this low dependency group. A further factor is that 1:1 funding was secured last year for a resident amounting to 12 – 18 hours per week. Also a resident is currently subject to re-assessment because of increased dependency. The staffing formula guide of the Department of Health computed for this home indicates a total of 138 hours per week which includes hours for social, recreational and cultural activities. Staffing rotas for the home for the first 2 weeks of January 2006 provide 108 and 105 hours respectively. The proprietor is now working in the home over 5 days, her hours are not included in the rota, but she indicates her care hours would be 20 per week (the same as the previous Manager). This does leave a shortfall between the required hours and those actually provided. Further factors have implications for staffing, these are: Currently there is no Registered Manager in the home. All staff including the Manager have left the home in the past year. There are 5 care staff the longest serving is 1 year the remaining 4 have commenced work in the past 6 months. There are training needs identified in this report. Most staff are still undergoing induction training. At this time none of the staff are involved in NVQ training. A relative in feedback to the Commission commented that “staff turnover seems excessive at the moment” In view of the above a requirement is made for the proprietor to provide the Commission with a review of the staffing hours and levels in the home by 31/03/06. This should include the total number of care hours worked, the dependency levels of residents following the reassessment process and the staff training programme in place. Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 22 Staff files of recently appointed staff were inspected. In one instance a written reference from the previous employer was not obtained. The reasons for refusal of another reference should be further pursued. POVA First checks had been carried out for staff prior to employment. A disclosure received must be further investigated and considered. Staff on duty were spoken to and indicated their desire for training. Some training had been provided in infection control and first aid. Both had completed the TOPPS induction process. Training was planned for Fire Safety, Food Hygiene and Medication Administration. Staff meetings have been intermittent. The proprietor has resumed staff meetings on a regular basis. The first held in January and minutes seen, indicated a positive commitment from staff members to improve the systems and routines in the home for the benefit of residents. From observations of interactions between staff and residents and from discussions with residents there was evidence of good, relaxed and positive exchanges between residents and staff. There was a relaxed atmosphere in the home. Repetitive behaviour of residents were dealt with in a sensitive and appropriate way by staff. Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 In the absence of a Registered Manager only one aspect of the Management standards was possible to assess – the Health, Safety and Welfare of Service users. Matters requiring action are: Risk assessments in relation to resident activity must be reassessed and rewritten. All staff must be given training in First Aid Data sheets should be obtained for all COSHH items used. EVIDENCE: There is no Registered Manager in the home at this time. Therefore this standard cannot be assessed. The Proprietor was formerly the Registered Manager and is to manage the home until a Registered Manager can be appointed. Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 24 It is recommended that Inspection reports are available in the home. This was requested by 2 relatives in feedback to the Commission. Policies and procedures were not inspected on this visit. Residents finances were spot checked and balances found to be correct. Care records are not adequate at this time. The proprietor intends to introduce a more centralised system of information which is precise and comprehensive. Fire records were inspected and all checks, drills and servicing had been carried out as required. Fire training has been arranged for some staff. Fire doors should not be wedged open and the proprietor intends to pursue purchase of automatic self-closing devices (door guards) after consultation with the Fire Officer. COSHH items were safely locked away. Data sheets should be obtained for all items used. All staff sleep-in at this home, therefore all staff must have first aid training. Risk assessments relating to resident activity must be reviewed and re-written as mentioned earlier in this report. Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 x 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 x 23 x ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 2 33 2 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 2 1 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x x x x x x 2 x Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA33 Regulation 18 Requirement Review staffing levels & provide the Commission with detailed required information by 31/03/06 Bedroom identified must be suitably equipped to present a more homely, comfortable, personalised appearance Two written references must be obtained prior to employment and any criminal offences investigated Risk assessments must be updated for all residents and include all activity Care plans must be re-written and include current information covering all areas of assessed need. The home must be kept free from offensive odours All staff administering medication must have accredited training Review personal expenditure of resident attending educational group. All staff must receive first aid training Electrical sockets in kitchen area DS0000004962.V274999.R01.S.doc Timescale for action 31/03/06 2 YA25 16(2)(c) 23(2)(f) 19(1) 28/02/06 3 YA34 31/01/06 4 5 YA42 YA6 13(4) 15 31/01/06 28/02/03 6 7 8 9 10 Iona YA30 YA20 YA12 YA42 YA24 16(2)(k) 13(2) 12(1) 13(4) 13(4) 26/01/06 31/03/06 26/01/06 31/03/06 26/01/06 Page 27 Version 5.1 must be fixed to wall and made safe 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 YA39 YA42 Good Practice Recommendations Inspection reports should be available in the home for visitors Provide data sheets for all COSHH items used. Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Iona DS0000004962.V274999.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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