Inspection on 22/09/06 for Manchester Learning Disability Partnership

This inspection was carried out on 22nd September 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Manchester Learning Disability... 29/08/07

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Manchester Learning Disability Partnership Short Breaks Service 228 Ryebank Road Chorlton Manchester M21 9LU Lead Inspector Michelle Moss Key Unannounced Inspection 22nd September 2006 09:00 Manchester Learning Disability Partnership DS0000065167.V304590.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 Manchester Learning Disability Partnership DS0000065167.V304590.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. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Manchester Learning Disability Partnership Address Short Breaks Service 228 Ryebank Road Chorlton Manchester M21 9LU 0161 881 8108 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) Manchester Learning Disability Partnership c/o Manchester City Council Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home provides accommodation and care on a respite basis for a maximum of four adults aged between 18 and 65 years old whose primary need for care is by reason of learning disability. The organisation must, at all times, employ a suitably qualified and experienced manager. The matters detailed in the attached schedule of requirements must be completed within the stated timescales. na Date of last inspection Brief Description of the Service: Ryebank Road is a care home that provides 24 – hour accommodation and support for up to four adults with learning disabilities, and associated disabilities, for short breaks that give carers/families a break from their care role. The building is a normal domestic dwelling set on a residential area in the south of Manchester with good access to local shops and amenities. The building is accessible for wheelchair users with tracking hoists fitted throughout the ground floor. The ground floor has a kitchen, lounge and dining room, and one bedroom with toilet and shower facilities. The remaining 3 bedrooms and bathroom facilities are located on the 1st floor with office space on the 2nd floor. There is an enclosed garden to the rear of the building. The weekly fees charged at time of this inspection were £13.50 per evening, approximately. The home will have a copy of this inspection reports made available to residents’, families and professional on request. A copy of the home’s Statement of Purpose and Service User’s Guide is always made available to read at the home. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the home was registered in January 2006. This information includes a pre-inspection questionnaire, completed by the home and submitted and an unannounced site visit to the Short Break Service office on the 16th June 2006 and a site visit to the home on the 22nd September 2006. This is the first inspection and site visit since the home was first registered with the CSCI. During the site visit time was spent talking to two people who stay at the home, a senior manager and staff on duty. Documents and files relating to people and how the home is run were also seen and the inspector looked around the home. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work the CSCI needs to do with the home in the future. What the service does well: These are some of the things that were found to be good about the home from talking with a person who used the service: The person that used the service liked staying at the home. They were taken to places including going to McDonalds, which they enjoyed. The staff made sure the dietary requirements were met and understood by everyone. This all showed that the opinions of people that used the service were respected. The staff had been trained in meeting the care needs of people who use the service. This showed that the staff team were sufficiently skilled to meet the everyday needs of people using the service, which in turn meant their health and welfare was safeguarded. The people who use the service were seen to be treated as individuals and the staff team provided care that reflected their rights and preserved their dignity and privacy. This meant that the staff team understood the importance of respecting people’s rights. The home was nicely decorated and fitted with aids and equipment that assisted the people who use the service to remain safe. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 6 The staff rotas showed that the staffing was set to meet the needs of the people that use the service. This meant there was enough staff to make sure everyone that used the service was kept safe and adequately supported. The staff team were themselves well supported by the management team and encouraged to develop their skills. This meant the people who used the service had staff working with them who could meet their social and health needs. When the home recruited staff they made sure the person was suitably experienced and that checks were completed that showed they were medically fit and suitable to work with vulnerable adults. This meant staff members were both adequately skilled and assessed as suitable to work with vulnerable people. What has improved since the last inspection? What they could do better: Care plans did not always have all the information about the changing needs of the people who used the service. This included details about how to keep them healthy, safe and how to respect their religious and cultural needs. Without this information the staff were not sufficiently kept informed about why meeting health and diversity needs were important to the person who was using the service. The care plan needed to be kept under review with written evidence that this was being completed. This would ensure the staff team were more informed about the updated needs of people using the service. The home needed to make sure that checks were made on the means of escape as well as other fire checks. This was important so that everyone knew the exits were always clear in the event of an emergency. The home needed to make sure it always had a First Aid box readily available that had adequate dressings so that emergency aid could be given if necessary. Without this being in place there was a risk that the right First Aid equipment might not be available in an emergency. The home needed to keep a record of the people coming to visit the home and why. The home needed to make sure that risk assessments were kept under review. This included checking what was recorded in the assessment and that this was happening in practice. This was important so that all staff knew what measures they needed to take to keep a person safe. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 7 The home needed to set up a nutritional screening assessment for all people that used the service. This would help to make sure the staff had all the information they needed to help keep everyone healthy. 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. Manchester Learning Disability Partnership DS0000065167.V304590.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 Manchester Learning Disability Partnership DS0000065167.V304590.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people who use the service were able to make informed decisions about the home through a structured admission procedure. EVIDENCE: The organisation had established a structured introduction programme for all new referrals to the service. This included completing a full introduction period and obtaining and completing comprehensive assessments of needs. The period of introduction would vary depending on the individual person. The home would offer as many tea visits and overnight stays necessary for people to make a informed decision about using the service or not. All prospective people who were considering using the service were given information about the home and about the staff that would help them. This information had been improved in recent months to make sure it was in a format that meant people who use the service were informed about what they should expect to receive, their rights and what they should do if they have any concerns. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who use the service had an informative care plan that highlighted some aspects of their needs. However, the positive aspect of the plan was compromised due to insufficient evidence about care needs of individuals, to demonstrate it was kept up to date/reviewed and that people using the service were invited to contribute in developing and reviewing the plan. EVIDENCE: The care plans of two people who used the service were examined. Both plans contained important information that informed staff about how to keep the person healthy and safe. This included having in place assessments regarding eating and drinking, mobility and epilepsy care. Also, each plan had an individual profile for each person. This was informative and told the reader important things. This was written from the view of the individual person. However, despite this good practice the plan had some weaknesses which compromised its aims and objectives. For example, there was no evidence to show the plan was being kept under review and updated when changes Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 11 became known. Although the service had a system in place to complete home visits where the care plan was reviewed with families, these were often completed 6 months apart. The reviews seen did not demonstrate that information obtained from these visit then resulted in the care plan being updated. Some of the risk assessments in place were initially completed in 2002 and last reviewed in 2005. Also the profile was not dated to confirm it was up to date. From talking with a person that used the service and staff on duty it was noted that their profile was out of date due to changes in family circumstances including their next of kin. One of the plans seen did make reference to the person’s religious beliefs. However, this didn’t included how the staff needed to respect their beliefs during their stay at the home. This extended to the staff being given the information that informed them about how they needed to support / respect the person to enable them to practice their beliefs. The second plan made no reference to the person’s beliefs. The plan also failed to provide details about meeting the person’s diverse needs. For example, how the person might wish to have their hair styled and cultural considerations when providing personal care. However, the two plans seen covered the details about preferred staff gender when they required help with personal care. The manual handling assessment of one person was examined and was found to be several years old. The information recorded was not clear and didn’t reflect the staff understanding about how they should support the person. It stated for transfers to use a hoist if required. It was unclear what the circumstances would be for using a hoist. The staff stated it was a two person assisted transfer. However, the assessment did not reflect this method. It was strongly recommended that the assessment was reviewed. Out of the two files examined one had a picture of the person. Neither plan had any evidence to suggest the person had been asked to contribute to writing up their care plan including being invited to sign the plan. Also the lack of dates in the different sections made it hard to determine if all parts were up to date and reflected current needs. The daily records made by staff about the people who use the service were found to be written respectful and provided detailed accounts of the time the person had spent at the home. This included what they had done and any concerns. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service were able to make choices about their life style, and supported to develop their life skills. EVIDENCE: The service’s main aim was to provide a short break service for adults with learning disabilities within a community setting. The location was good for accessing events due to the home being located next to a sports complex / park. A person that was using the service at the time of the visit described their experiences of the service as always being positive. They spoke about liking the staff and their stays always included having the opportunities to go out. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 13 From examining two care plans, one included an eating and drinking assessment/ guidelines which informed the staff about how they needed to keep the person healthy and safeguard them from adverse affects caused by having Dysphagia. However, no nutritional screening plans were in place for other people who used the service. By having these assessments the home could identify the individual persons likes and dislikes and detail any specialised dietary needs. The home explained that work had been completed with health professionals to look at the recording system for promoting good health. A new assessment tool was being introduced and anticipated it would address the identified weaknesses in the current system. As already covered in this report the diverse needs of people who use the service was not well covered in the care plan. This included details about cultural dietary needs. However, a file was kept in the kitchen which provided staff with information about the different dietary needs and what should be respected. The staff showed they recognised the different arrangements that might be required to be used for meeting the religious needs of people that use the service. Although the care plans was not adequately detailed regarding meeting diverse needs, it was noted from talking to a person that used the service that in practice diverse needs were valued and promoted by the staff. The home sought the views of families about the home through their annual quality assurance surveys. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service had their personal and healthcare needs met by the home. This included ensuring that the care of medicines was managed well and having good arrangements in place for safeguarding their health and welfare. EVIDENCE: The home was a short break service that provided respite for carers/families. The home therefore did not take responsibility for overseeing the day-to-day health monitoring of people. However, the home ensured they held important health information that might be needed if during the person’s stay they became ill and required emergency treatment. Where medical conditions were known the home had obtained all the required information to ensure they could promote good health during the person’s stay at the home. This included having guidance / care plans which detailed the specific condition and how it affected the individual. For example, the care of epilepsy. A care plan was in place that provided the staff team with information Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 15 about the person’s seizures, how it might affect them and what type of medical intervention might be required. From reviewing two care plans it was noted that people using the service had been asked about who they might want to provide personal care. For example, their preference of male or female member of staff. Also, nighttime considerations were recorded. This included how they liked/needed their bed to be set up. The time the person preferred to go to bed and get up in the morning was also recorded. On speaking to one person that used the service they confirmed they decided when they wished to go to bed and when to get up in the mornings. On case tracking two-care plans evidence was found that demonstrated that the care of medicines in the home was managed well. This included, all medication charts seen providing an audit trail of medication administered. The staff administering medication were required to complete a competence based assessment. However, it had been acknowledged that staff also needed to receive additional training on medication. The home confirmed this was being sought. The home was obtaining patients advisory leaflets regarding medication being administered wherever possible. The staff on duty explained the procedure used when checking in medication. This included staff checking the pharmacist labels and information the home had on prescribed medication. If any variations were noted or anything was unclear on the labelling the home’s policy was to contact the person’s GP for confirmation. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service had information made available to them that told them about how they could raise a concern. Also, policies and procedures and training programmes were in place that ensured all staff knew about safeguarding people using the service from all forms of abuse and neglect. EVIDENCE: The home explained that the service had ensured that people using the service were given access to information about raising their concerns or worries about the care they received from the home. This was being updated so that it was in a format that helped to ensure that as many people using the service could gain an understanding about the procedure. The staff on duty confirmed they had been trained in the protection of vulnerable adults and was familiar with the authorities policy on adult protection. All new staff recruited by the authority were required to undergo a Criminal Records Bureau check including being check against the POVA list, prior to commencing employment. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people that used the service had their health and wellbeing protected by the premises that were in a good state of cleanliness. However, some aspects of Food Preparation, Fire Safety and First Aid were not adequate to safeguard people using the service from risk of harm and meeting diverse needs. EVIDENCE: Fire records were adequately maintained including having a detailed record of all testing that had been completed. The only thing missing from the records was not recording that a check had been completed on the means of escape. The lounge, bedrooms, bathrooms and kitchen were seen during the visit. These areas were found to be clean and designed in a way that reflected the needs of the people that used the service. One bedroom was located on the ground floor and was adapted to support people with physical limitations. The room was fitted with overhead tracking and a raising and falling bed. Also, an adjoining bathroom was accessible. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 18 The home was checking temperatures of water outlets accessed by people using the service. Also temperature readings were maintained for fridge and freezers. However, the home was not using a Food Hazard Analysis assessment to ensure the food preparation was adequately safeguarded. The home wasn’t using coloured chopping boards or using designated chopping boards for none meat products. In meeting food hygiene standards and respecting religious believes the home was strongly recommended to review their practices regarding food preparation. The home had a First Aid box. This was examined and found to have dressings that were out of date. The home was made aware of the findings. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service were benefiting from a staff team that knew their roles and responsibilities, and were receiving support and supervision from their line manager. However, the recruitment checks necessary to ensure people wishing to work with vulnerable adults were not adequately robust. EVIDENCE: The staff team spoken with were clear about their roles and responsibilities. The manager had consulted with staff to ensure that they had a greater understanding of their training needs. The home was also securing training as an outcome of the exercise. The relationship between the people who use the service and staff was observed as very positive. The staff team were skilled in effective communication. This meant that the people who used the service could be actively involved in making choices about their daily activities. The staff team spoken with confirmed that staff meetings took place on a regular basis and that they received regular supervision. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 20 Training was well delivered by the organisation. The range of training included: - Person Centred awareness, Autism Awareness, Food Hygiene, LDAF, NVQ, Understanding Sensory, Moving & handling, Rectal Diazepam, Dysphasia, POVA and Recording with Care. From information provided by the home it was confirmed that over 87 of staff held a NVQ qualification in care. Information received from the home confirmed they had in place policies and procedures on the recruitment of staff. It was found that overall a rigorous recruitment and selection procedure was in place. This included face-to-face interviews of which one person who used the service would be invited to sit on the panel. Also, two written references and CRB/POVA checks were completed before an appointment was confirmed. The home confirmed all staff members were provided with copies of the Code of Practice published by the General Social Care Council. However, what was not clear was the length of employment history obtained. It was questioned that the authorities application might only ask for the past 10 years rather than what is required under the Care Home Regulations 2001 which states “ A full employment history, together with a satisfactory written explanation of any gaps in employment”. The home was required to investigate this to ensure the practices used by the authority to recruit staff met these regulations. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements within the home were based on openness and respect, had effective quality assurance systems developed. However, the home did not have a registered manager responsible for the service. EVIDENCE: The home’s management structure has an Assistant Network Manager (ASM) who has day-to-day responsibility for the safe running of the home. They are also responsible for another home in the Short Break service. They are responsible for supervising the staff team and to ensure that standards of care are being maintained. They do this through allocating a large proportion of their time at the home working and spending time with people and monitoring the homes recording and operational systems. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 22 They are line managed by the Team Manager, (who was present at the inspection site visit), who has responsibilities for the Short Break and other services within the MLDP. The service has been in discussion and negotiations with the CSCI and a proposal of who is to be proposed as the registered manager has been agreed but has not yet been implemented. Information provided by the home indicated they had a number of important policy and procedures that safeguard the people who used the service. These included: - Control of Substances Hazardous to Health, Care of Medicines, Code of Conduct, Disposal of Clinical waste, Fire safety, Food safety, First Aid and Moving and handling. The home confirmed that work on self-monitoring the service was well underway, including setting up an annual survey. This survey was aimed at formally seeking the views of people who use the service and other stakeholders, like parents / carers and health professionals, about their opinions regarding the quality of service provided by the home. Once completed the findings would be published and copies provided to the people who use the service and the Commission for Social Care Inspection. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 x 32 3 33 X 34 2 35 3 36 3 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 24 N/A 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 YA6 Regulation 15 Requirement The home must have a written plan which details about the person’s needs. This must include:• • • • How their health and welfare will be met. Demonstrates it is being kept under review. Demonstrates it has been updated when changes have become known. That the diverse needs of people are acknowledged and incorporated in to the care delivered. 31/12/06 Timescale for action 31/12/06 2 YA9 14 • All risk assessments must be kept under review and updated where changes become known. 3 YA24 23 The home must ensure it takes 30/10/06 adequate precautions against the risk of fire. This includes ensuring part of the checks /testing completed includes checking the home’s means of escape of which a record of these checks is maintained. Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 25 4 YA30 13 5 6 YA30 13 Schedule 2 YA34 The home must have as part of their arrangements to prevent the spread of infection adequate systems in place for the preparation of food. The home must ensure it has available a first aid box which is contains adequate in date stock. The authority must ensure a full employment history is obtained for all staff employed to work with vulnerable adults. This must include any gaps in employment satisfactory explained. 30/11/06 30/09/06 30/10/06 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 3 4 Refer to Standard YA9 YA15 YA17 YA30 Good Practice Recommendations The home should review all risk assessments that are over 12 months old to ensure they reflect the current needs of the person. The home should consider holding a visitors book that records the people who are entering the home. The home should have in place for all people who use the service a nutritional screening assessment. The home should review the use of chopping boards so that boards are designated for none meats products. Also consideration should be made to the cultural differences requirements when preparing food. The home should have in place a Food Hazard Analysis assessment for the preparation and cooking of food, especially meats. 5 YA30 Manchester Learning Disability Partnership DS0000065167.V304590.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Manchester Learning Disability Partnership DS0000065167.V304590.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!