Inspection on 12/06/07 for Little Arches

This inspection was carried out on 12th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Little Arches 07/11/05

Little Arches 05/01/05

Little Arches 10/08/04

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 Little Arches 83 Cambridge Street Clifton Rotherham South Yorkshire S65 2ST Lead Inspector David White Key Unannounced Inspection 12th June 2007 08:30 Little Arches DS0000003135.V320649.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 Little Arches DS0000003135.V320649.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. Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Little Arches Address 83 Cambridge Street Clifton Rotherham South Yorkshire S65 2ST 01709 517461 NONE NONE 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) Mrs Andrea Briggs Mr. David Lambert Mrs Andrea Briggs Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: Little Arches is a 4-bedded unit for adults with learning disabilities. It is owned by Mrs Andrea Briggs and Mr David Lambert and Mrs Andrea Briggs is both the registered person and manager. A small staff team of four enables Little Arches to provide a homely approach to care enhanced by the small size of the group and the ratio of one member of staff to people using the service at all times. This ratio increases on occasion such as reviews, trips, appointments etc. The building is a detached property close to Rotherham town centre and people living at the home all have private accommodation for use as bedrooms and share the rest of the house that includes a dining room, large lounge, conservatory, patio and garden. People at the home participate in the daily routine of the home including shopping, cooking and cleaning. The current fees for the home at the time of the site visit on 12th June 2007 were from £650 to £800 per week. This does not include costs for hairdressing, chiropody and toiletries. The home has a statement of purpose that explains the aims, objectives and philosophies of the home. Each person is given a service user guide that provides information about the care and services on offer at the home. The most recent inspection report is available for people to look at. Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • Reviewing information that has been received about the home since the last inspection. Information provided by the deputy manager on a pre-inspection questionnaire. Comment cards returned from 3 staff members and a professional who has contact with the home. This report follows an unannounced site visit undertaken on the 12 June 2007. This visit was carried out by one Regulation Inspector and took 6.5 hours with 4 hours preparation time. Time was spent talking to four people who live at the home; a member of the care staff and the manager. Records relating to people at the home, staff and the management activities of the home were inspected. During the visit care practices were observed, where appropriate, and time was also spent watching the general activity in the home. This helped in gaining an insight into what life is like for people living in the home. The manager was available throughout the inspection and the findings were discussed with her at the end of the site visit. What the service does well: People living at the home receive a good standard of care from a settled, caring and committed staff team who have a good understanding of their needs and who act in their best interests. Each person is encouraged to be independent and to make their own choices and this helps them to have control over their lives. People at the home have opportunities to develop their personal skills through involvement with local day services and education centres. They enjoy a range of activities that enables them to pursue their leisure interests and to have involvement in the local community. Staff are respectful to people who are living in the home and this helps to maintain the person’s dignity when receiving support from staff. A professional who has contact with the home says that it has a “happy atmosphere” and this could be seen at the time of the site visit. This enables people living at the home to feel comfortable and safe. Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 6 The home is well managed so that good standards are maintained for people living at the home, their interests are put first and they are involved in decision-making about how the home is run. What has improved since the last inspection? What they could do better: The systems for recording what medications people should be having could be clearer so that there is less chance of any risk to peoples’ health from possible medication errors. An assessment of the fire risks in the home will help in identifying any specific risks to the fire safety in the home and enable actions to be put in place to reduce these risks and keep people safe. The stair lift could be serviced to make sure that people are not at risk of any harm if needing to use it. Food safety practices could be improved to prevent any health risks to the people living at the home. Written references could be obtained for all new staff before they start working at the home so that people living at the home are protected from any potential harm. Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 7 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. Little Arches DS0000003135.V320649.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 Little Arches DS0000003135.V320649.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Proper pre-admission procedures are in place so that any person who is considering moving into the home can feel confident that their needs will be met. EVIDENCE: There have been no admissions to the home since the previous inspection visit, however, proper pre-admission procedures have been followed in the past to make sure that only suitable people are admitted to the home. Information about the person’s care needs is collected from all available sources such as the placing authority to support the home in their decision making about whether they have the skills and resources to meet the person’s needs. The registered providers have their own needs assessment form to gather information about the person’s specific needs. People who are thinking about moving into the home have the opportunity to visit beforehand with their relatives and/or representatives to help them with their decision-making. Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People using the service are encouraged to be independent whilst taking into account any risks that need to be considered. EVIDENCE: People using the service said that their independence is encouraged and that they can live their lives as they wish. The aim of the home is to enable people to make their own choices and this was observed at the time of the site visit. Staff have a very good understanding of the needs of the people who are living at the home and receive appropriate training to support them with this. A professional who has involvement with the home made comments that the “service is astute and knows the individuals very well” and that “each person is valued for who they are”. Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 11 Each person has a person centred plan which places emphasis on how they prefer to be supported in meeting their aims and objectives. The plans focus on maintaining the skills and independence of each individual and takes into account their personal choices as to how this is to be done. The information includes a “health action plan” which includes details about the person’s food likes and dislikes so that people can be encouraged to eat a nutritious diet that they enjoy. There is also other information about health care professionals who are involved in the person’s care and there are records of reasons for any appointments and outcomes from these so that staff know what they need to do to support individuals in meeting their health needs. One person living at the home has recently experienced some mental health problems and following a care review it is felt that this person needs more one to one care. This is being arranged in order to meet the person’s health needs and to meet the needs of other people living at the home. People living at the home said that they regularly meet up with staff to discuss their care. There is a key worker system at the home that enables staff to spend time with people on a one to one basis and the people using the service particularly liked this aspect of their care. Care plan reviews are held with relatives and other people who are involved in the person’s care, however in some cases there are no records from these meetings. Without this information there is risk that staff may be unaware of any changes to a person’s needs and what they need to do in response to this. A range of individual risk assessments is in place to promote the independence and safety of people at the home. The assessments include information about why decisions have been made where people could be restricted in what they are able to do and these are agreed with the person. One person sometimes behaves in a way that challenges the service, but there is a plan in place to guide staff on how this should be managed with the least possible distress to the person exhibiting the behaviour and to others who may be at risk from it. Whilst the information in the care records is detailed and informative, it is recommended that it is better organised as some of the information is not always easy to access. Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People living at the home enjoy a very fulfilling lifestyle and are involved in social and occupational activities in the local community. EVIDENCE: The home is committed to helping individuals to maintain their independence and to enable them to develop their personal skills and pursue their leisure interests. One person said that she attends a work placement scheme at a local centre where she is developing her daily living skills and doing adult literacy classes. Another person at the home attends a local day service and someone else has a job helping to make coat hangers and receives some payment for this. People at the home have a lot of opportunity to be involved in the local community and said that they regularly visit the local shops, pubs and other attractions. One person is a member of the local church choir and has a lot of involvement with the church. Activities are planned in house Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 13 meetings that are attended by both people who are living at the home and the staff team. Staffing levels are planned around the needs of the people at the home so that extra staff are on duty for arranged outings and other planned activities. Each person has the opportunity to go on holiday and people at the home said they are looking forward to going to Skegness and Majorca later this summer. At the home people are encouraged to help out in preparing their meals where they are safe to do so and they are supported by staff to clean their bedrooms and attend to their laundry so that they can develop their personal living skills. Most people who are living at the home need staff to support them when using transport, however one person who is able to use public transport independently is encouraged to do so. All the people who are currently living in the home are able to communicate their needs through verbal means but sometimes require assistance in being able to read and understand information. Some written information is available in picture format to support people with this and the home has close links with advocacy services that are accessed to assist people with their decision-making in order to make sure that their rights are protected. People living at the home are encouraged to maintain relationships with their family and friends and one person said that a friend had recently visited her at the home. Menu planning is carried out with the people at the home to suit their personal tastes. People said that alternative meals are available if they do not like what is on the menu. The menus are varied and consider non-meat and healthy eating options. The care records show that each person’s weight is regularly monitored and any health needs that are identified from this are addressed in the person’s individual plan. Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The personal and health needs of people living at the home are well met although the medication procedure could be improved on to better protect people living in the home. EVIDENCE: Staff aim to promote the independence of the people living at the home so that they have control over their lives. People could be seen to be receiving support in a sensitive and dignified manner and people at the home feel that their privacy is “always respected”. People’s personal and healthcare needs are clearly recorded in their individual plans and there is clear guidance for staff as to how this is to be achieved. Each person at the home has a General Practitioner (GP) and has access to dental and chiropody services. Referrals to specialist services are made as required and staff support people in attending appointments. People living at the home receive support from the local Community Team for Learning Disabilities and those with mental health problems are supported by the local Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 15 mental health services. One person has recently experienced deteriorating mental health and this matter was immediately referred to a local assessment and treatment team so that the person could receive the proper specialist care and treatment. Health care information is well recorded in explaining the reasons for appointments and outcomes from these so that staff receive clear guidance on what they need to do to promote peoples’ health. None of the people living at the home currently administer their own medication. Medication is stored safely and there are procedures in place for the receipt and disposal of medication and all medication is signed for. All staff who are responsible for administering medication in the home receive the appropriate training. The home is using a system that requires staff to hand write all the details of medication onto the medication administration sheet. However in one case the information on the medication record sheet did not tally with the instructions on the box of the prescribed medication. Whilst a check of the records against the medication supplies confirmed that the correct dosage of medication is being given, the inaccuracy of the information on the medication administration sheet could have led to the person not receiving the proper medication. This matter was brought to the attention of the manager and was dealt with immediately. As a result from this the manager said that the home would be reviewing its current medication systems to prevent a reoccurrence of this situation. Whilst the home has a system for auditing the medication procedures, the issue with the incorrect information on the medication administration sheet had not been identified through this process. Information has now been obtained from each person about arrangements that are to be put in place in the event of their death so that their specific wishes can be carried out. Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Clear complaints and safeguarding policies and procedures are in place to make sure that peoples’ concerns are listened to and acted on and they are safeguarded from any potential harm. EVIDENCE: The home has a complaints procedure in place that details how any complaints are to be made and what will happen afterwards and each person is given a copy of the complaints procedure. People at the home know who they would need to speak to about any concerns and said they would feel confident that the manager would deal with any issues of concern properly. The home has a copy of the local authority policy and procedure on how to protect vulnerable adults from abuse. The manager said that these guidelines would be followed if a matter needed to be referred relating to abuse. All staff receive information about abuse awareness at the point of induction and this is updated regularly. Staff have a good understanding of what would constitute abuse and the actions they would need to take if abuse is suspected or had occurred. Individual risk assessments are in place for a person who displays challenging behaviour so that risks from the behaviour can be identified and measures can be taken to reduce risks. Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People live in a homely and comfortable environment that is well maintained. EVIDENCE: The home has a warm and welcoming feel to it. A professional who has contact with the home made comments about the “happy atmosphere” there, and on the day of the site visit there was a lot of good humour between the people living at the home and the staff. The home has two floors with bedroom accommodation on the first floor. The home also has an adjacent garage that has been converted into a selfcontained unit with bedroom, kitchen, lounge and bathroom facilities. The home has ramped access and there is a stair lift between the ground and first floor to support people who may have mobility problems and aids and adaptations are in place to support people to be independent. Each person has their own bedroom that is personalised to suit their individual tastes and Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 18 people have easy access to bathroom and toilet areas. People who live at the home said that they like their bedroom and the general location of the home with its easy access to local amenities. The home has a lounge, a dining room and a conservatory so there is sufficient seating space for people in communal areas of the home. Most of the home has been re-decorated since the previous inspection visit and there are further plans to update the bedrooms. There are also plans for a new conservatory to be built to replace the existing one. The home was generally clean on the day of the site visit. There are laundry facilities so that the personal clothing and bedding of people living in the home can be attended to and procedures are followed to reduce any risk of infection. A new combination boiler has been fitted with pre-set valves to regulate hot water temperatures and random monitoring of the water temperatures is to take place to make sure that the new systems are working properly. Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. A settled staff team and improvements to staff training mean that people living at the home are receiving good consistent standards of care from a staff team with the skills and knowledge to meet their needs. Further improvements are needed to one aspect of recruitment procedures to safeguard people at the home from any potential harm. EVIDENCE: The home has a very settled and stable staff team. One staff comment card said, “I do not think anyone could wish to work in a better place”. There is low staff turnover so that people living at the home are receiving consistent care from staff that knows them very well. Staffing levels are good and people at the home said that they are always able to access staff for support when needed. Staffing rotas are flexible and are planned around the needs of people at the home. Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 20 Since the previous inspection visit the manager has managed to find an alternative umbrella body to carry out police checks on all new staff so that all staff have now had a satisfactory police check before starting work at the home so safeguarding people from harm. The staff file of the most recently appointed member of staff shows that most of the necessary pre-employment checks have been done, however, there is no record of any written references on the person’s file. The manager explained that written references had never been received on behalf of the person and although she had received some verbal references over the telephone these had not been recorded. These practices potentially put people at risk from harm and the manager is addressing this issue as a matter of priority. In the past the home has had difficulty in accessing foundation training for the staff team. However, the manager has developed links with other care homes in the local area and this has enabled staff to access their training programmes. All the staff have completed the National Vocational Qualification (NVQ) programme to enhance their skills and knowledge in meeting the needs of the people in the home. Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People using the service benefit for a well managed home in which their needs and interests are put first. Some improvements to aspects of health and safety would help to promote their safety. EVIDENCE: The registered manager is also a joint proprietor of the home. She is experienced in working in the care sector and has a very good understanding of the needs of the people at the home. Since the previous inspection visit she has completed a management qualification to develop her management skills. People in the home and staff made comments that the manager is “hands on, approachable and supportive”. All the comments from staff indicate that they Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 22 have good relationships with the management of the home and people living in the home said that they have confidence in the manager’s abilities. The manager has an open approach to running the home, which encourages everyone to have their say in how care and services could be improved. Care is person centred to meet each person’s individual needs and to help them to enjoy a good quality of life. The home has systems in pace to seek the views of people about the running of the home. People living at the home had the opportunity to complete a questionnaire asking them about their opinion of the care and services they receive. The questionnaire was in picture format to assist those with communication difficulties to provide their comments. Regular house meetings are held when staff and people at the home meet together to discuss matters in the home and to plan for activities and records are kept from the meetings to show how decisions have been made. In individual files and on display in the home there are certificates of the achievements of people living at the home to show what progress they have made. Staff said their views are encouraged and staff meetings are frequently held to support this. The manager said that she is in regular contact with relatives who are invited to care plan reviews along with professionals who are involved in a person’s care. Staff receive a range of health and safety training to support them in meeting people’s needs safely. Issues from the previous inspection visit have since been addressed satisfactorily. A new combination boiler has been fitted so that the heating and water systems are more modern and safer. Portable Appliance Testing (PAT) has been carried out on all the electrical appliances in the home to promote people’s safety. Some aspects of health and safety in the home do need addressing. The home has a stair lift and although it is rarely used it is due for servicing to make sure that people’s safety is not at risk if they need to use it. Fire safety is well maintained through fire safety checks and regular staff training. However, a fire risk assessment of the premises needs to be carried out to identify any environmental factors that could trigger a fire and control measures that need to be put in place to reduce any fire risk. Daily records of fridge and freezer temperatures are maintained to promote good food safety practices. However, on inspection of the fridge contents one type of sandwich filler had exceeded its use by date and some condensed milk had been opened but was not sealed or dated so it was unclear when it needed to be consumed by to prevent any risks to people’s health. The manager immediately dealt with this matter to prevent any risks to the people at the home. Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 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 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13 (2) Requirement All medication details including dosage and administration instructions must be kept up to date and accurately reflect the medication being prescribed. This will make sure that each person receives the correct dosage of medication. Two written references must be obtained on behalf of each new member of staff before they start work at the home so that people who use the service are not put at any risk of potential harm. The registered manager must make arrangements for the stair lift to be serviced in order to make sure that it is safe for people to use. Food safety practices must be followed so that people using the service are not at risk to their health from: • Foods that have exceeded their use by date. • Foods that have been opened but not sealed or dated so it is unclear by DS0000003135.V320649.R01.S.doc Timescale for action 12/06/07 2. YA34 19 (1) (i) 12/07/07 3. YA42 13 (4) (a) and (c) 12/07/07 4. YA42 16 (2) (j) 12/06/07 Little Arches Version 5.2 Page 25 5. YA42 23 (4) when the food must be eaten. The registered manager must 12/07/07 make arrangements for a fire risk assessment to be carried out on the premises so that any areas of risk can be identified and action taken to minimise these risks. 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. Refer to Standard YA6 Good Practice Recommendations Information from care reviews should be recorded and held in the person’s care records so that staff are clear about any changes to the person’s needs and the actions they need to take to meet these. Information in the individual files of each person living at the home should be better organised so that it is easier to access. 2. YA6 Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Little Arches DS0000003135.V320649.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!