Inspection on 22/11/06 for Mill Dale

This inspection was carried out on 22nd November 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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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 Mill Dale 41 Nunroyd Heckmondwike WF16 9HB Lead Inspector Tracey South Unannounced Inspection 22nd November 2006 09:10 Mill Dale DS0000067159.V309310.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 Mill Dale DS0000067159.V309310.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. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mill Dale Address 41 Nunroyd Heckmondwike WF16 9HB 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) 01924 325698 www.kirklees.gov.uk Kirklees MC Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/a Brief Description of the Service: Mill Dale is owned and managed by Kirklees Metropolitan Council and provides a service to younger adults with a learning disability. The home is situated near to the town centre of Heckmondwike. The home is on a bus route for Heckmondwike, Dewsbury and Batley. The nearest train station is in Dewsbury. Mill Dale is a single storey building. There are two communal lounge areas, two dining rooms, one of which has a kitchenette. Other facilities include a large kitchen, two offices, a laundry room and a sensory room. The building is surrounded by large gardens and patio areas. Mill Dale benefits from having a hearing loop installed, to assist those people with hearing problems. Mill Dale is a no smoking house. Information provided by the home prior to the inspection indicated that the fees range from £334.79 to £1,043.78 per week. Service users are expected to pay the cost of activities such as swimming, cinema, and meals out at the pub. The service provider ensures that information about the service is available to prospective service users and the current service users by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection to take place at Mill Dale. The home was registered with the Commission for Social Care Inspection in April 2006. As part of this key inspection the Commission for Social Care Inspection (CSCI) undertook a visit to the home. Alongside this, the staff at the home also completed a pre-inspection questionnaire, which was returned to the Commission before the inspection as requested. Information from this questionnaire was also used for this report. The inspector arrived at the home at 9.10am and left at 3.20pm. Whilst at the home, key documents such as care records, care plans, daily records and some of the home’s policies were looked at. A tour of the home was also undertaken. Three members of staff were spoken with, along with the manager. The inspector spoke with two service users. Surveys were sent to service users and their relatives/carers. Four service users surveys were returned. Six relative/carers surveys were returned. In writing this report, information and evidence was not only obtained by way of visiting the home, but information and evidence was obtained from notifications sent to and information obtained by Commission for Social Care Inspection. There were 5 service users staying at the home on the day of the inspection. The majority of service users were seen leaving the home during the beginning of the inspection, to attend the local day centre. Only one service user remained at the home for the duration of the inspection. The inspector would like to thank everyone for their assistance during the inspection process. What the service does well: Prospective service users are thoroughly assessed prior to being offered a short stay placement at the home. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 6 Service users are given information about the home prior to their short stay. They are also available to visit the home, as many times as they wish before staying overnight. People who took part in the Commission’s survey felt they received enough information about the home prior to their stay. Service users are encouraged and supported to participate in their chosen activities as well as training and education. The cook at Mill Dale has spent time with service users in order to establish the type of meals people prefer. Halal meals, as well as specialist diets, are catered for. The accommodation at Mill Dale is excellent, providing a homely and comfortable environment for service users. What has improved since the last inspection? This is the first inspection to take place at the home. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 7 What they could do better: 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. Mill Dale DS0000067159.V309310.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 Mill Dale DS0000067159.V309310.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 and 4 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users’ are thoroughly assessed prior to being offered a short stay placement at the home. Service users are able to visit Mill Dale in order to “test drive” the home prior to their short stay placement. EVIDENCE: Mill Dale offers short stay placements to younger adults with a learning disability. All referrals come via the Community Learning Disability Team based at Dewsbury. Two prospective service users’ files were examined. There was evidence in both files that assessments had been provided by the funding authority. The assessments clearly outlined the level of support the person required during their stay at the home. The home also receives a risk assessment, “setting the scene”, which outlines identified risks. On receipt of this information the staff at Mill Dale are able to make an informed decision as to whether or not they are able to meet the prospective service user’s needs. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 10 There was good evidence in the two files examined, that prospective service users are able to visit the home prior to their short stay placement. There is no set timescale as far as how many visits people are allowed. The manager explained that this depends very much on the individual, in how long they need before they feel comfortable about staying overnight. The service user surveys returned to the Commission for Social Care Inspection indicated that people felt they had received enough information about the home prior to their short stay visit. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are generally of a good standard. Service user participation in the care planning process needs to improve. Service users had mixed views about whether or not they are able to make their own decisions. Service users undergo a risk assessment prior to being offered a short stay placement at the home. EVIDENCE: Two service users’ care records were examined, both of which contained a care plan. One of the service users has been visiting Mill Dale since September 2006, after transferring from another service. The care plan in place had been forwarded from that service and is being used as the current care plan. The inspector was concerned that the care plan had not been reviewed during any time since this person’s admission and there have been no amendments to the plan, despite this person moving from one service to another. The plan did not include the person’s religious needs, despite the service user stating she was a Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 12 Buddhist. Furthermore, there was no evidence of a current risk assessment in place. The second care plan related to a service user who has used this service for a number of years. There was evidence that the care plan has been amended as the person’s needs changed. This person had a risk assessment in place. The staff must ensure that all care plans are current and up to date. They must also be able to demonstrate that the service user has been actively involved in the formulating of their care plan as well as the review process. The care plan should be available in a format and language that the service user can understand. The manager explained that this is currently being addressed and showed the inspector a copy of the documentation to be adopted. The new document includes graphics as well as plain English. As part of the surveys, service users were asked if they make decisions about what they do each day. One person said they never did, and three people said they sometimes did. Service users were also asked if they could do what they wanted during the day, in the evening and at the weekend. Two people said, no, to all three sections of the question. One person said yes to all three sections. And one person said yes they could do wanted they wanted to during the day, but didn’t respond to any other sections of the question. Care plans examined recorded information to suggest that service users are encouraged and supported to make their own decisions. However, in view of the comments made in surveys, the management team must ensure that this is being put into practice. The manager explained that risk assessments are completed prior to the person being offered a short stay placement at the home. Additional risk assessments are implemented if risks are identified during the person’s stay at the home. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to continue with their choice of activities. The routine of the home promotes independence and choice. Service users enjoy their meals and mealtimes. EVIDENCE: Service users who spend time at Mill Dale are supported to continue with their educational and occupational commitments. Many of the service users attend local day centres. Younger service users are supported to attend school whilst at Mill Dale. A couple of the service users attend college and a small number of people take part in voluntary work based placements. The manager spoke positively about the home having good links with the local community, even in such a short time that the home has been opened. She explained that the home had a number of visitors, mainly children, on Halloween night. Service users and staff were able to enjoy a night of “trick or Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 14 treat”. The manager sees this as a positive indication that local residents are happy to integrate with people who come to stay at the home. The manager explained that the current staffing levels are to be increased as funding has been approved for an additional two staff. This will enable the management staff to be more creative with the duty rotas. The extra hours will enable staff to engage in one-to-one activities as well as being able to have a higher staff ratio when caring for people with more challenging needs. The intention of this service is to give parents and adult carers a break from looking after their loved one. However, service users are able to keep contact with their carer during their stay at Mill Dale. The manager explained that some relatives/cares sometimes visit the service user but in most cases contact is made by telephone. Service users and staff share good relationships with each other. This was observed during the inspection visit. Service users are encouraged to participate in jobs around the home. Some service users take responsibility for the laundering of their own clothes, supported by staff. The daily routines and house rules are very relaxed as the manager is keen to promote a home from home atmosphere. Each service user has their own bedroom and they are able to bring items with them during their stay, in order to personalise their room. The home recently carried out a quality survey in which people said they would like to choose the room they have when the come into Mill Dale. The outcome was that the management staff will try to locate service users with the bedroom of their choice but it was made clear that this is not always possible, and the reasons why not. The layout of the building means that service users can sit in comfort along with other service users or alone if they prefer. There are a number of lounges to accommodate such preferences. The ethos of the home is about accommodating service users wishes and preferences. Mealtimes are flexible. Staff have their meals alongside service users creating a homely atmosphere. Dining rooms are cosy and provide a comfortable environment for service users to enjoy their meals. The home benefits from having a part time cook employed to assist with the preparation of meals and menu planning. Staff and service users spoke positively about the meals provided. The manager explained that the cook has spent time with service users getting to know their likes and dislikes. Service users receive a well balanced diet. One service user said she enjoys her meals and is able to have her favourite meal when she comes to stay at Mill Dale. Halal meals are provided for when required. The cook is able to easily access Halal products locally. Other than low fat diets there are no specialist diets currently catered for. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 15 A number of service users enjoy eating out. One service user was going out for a pub lunch, with a member of staff, on the day of the inspection. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional needs are met. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: The care plans examined described the level of personal care support the service user requires, as well as how it will be delivered. This included the persons’ preferred routine in respect of getting up and going to bed. The manager explained that as the home only employs two male staff it can be difficult to match the same gender when offering personal support to service users. The manager is to request that one of the two new members of staff to be recruited will be of male gender to ease the current problem. Medical and GP details are recorded in service user case records although the manager explained that people’s health care needs stays with the parents/ carers. The home will ensure that service users receive appropriate medical attention whilst staying at Mill Dale. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 17 The manager explained that the home has good links with the community nurse who offers support and is actively involved in the home. The Community Access Team provides staff with the support they need in managing violence and aggression. The home operates a safe and effective medication system. The co-ordinators and night staff are responsible for administering service users’ medication. Very little medication is kept at the home. Medication supplies examined were correct. The medication policy is kept in the medical file along with a list of staff who are authorised to administer medication. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure that is clear and easy to follow. Service users are protected from abuse, neglect and self-harm. EVIDENCE: The complaints procedure is written and produced by Kirklees Metropolitan Council. The procedure is clear and easy to understand. The procedure is also available in CD format as well as other languages, upon request. The procedure is displayed in the front entrance of the home. Service users are also informed of the procedure within the home’s statement of purpose and service user guide. The home has received two complaints since opening in April 2006. Both complaints examined, had been dealt with appropriately, in accordance with the complaints procedure. Staff must remember to sign and date when they make an entry in the complaints log. Service users were asked as part of the surveys, if they knew who to speak to if there were not happy. Two people said yes they did, two people said they didn’t know. When asked if they knew how to make a complaint, one person said yes they did. Three people said they didn’t know and one said they would tell mum and dad if anything was wrong. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 19 Surveys completed by relatives indicated that they were aware of the complaints procedure. The manager was able to demonstrate a good understanding of adult protection matters and asks as an enquiry co-ordinator when allegations of abuse are reported to the local authority, that is, Kirklees Metropolitan Council. Six staff have recently attended the council’s adult protection briefing sessions which includes the launch of their new adult protection policy. The remaining staff will be booked on future briefing sessions. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, and comfortable environment. clean and hygienic. EVIDENCE: Mill Dale is a new building and the décor of the home is of a very high standard. The fixtures and fittings are of a high quality creating a homely and comfortable environment for service users. The kitchen is large and fitted with a range of modern appliances. Fly screens have recently been fitted as recommended by the environmental health officer. The home offers access to local amenities, local transport and relevant support services. The premises are in keeping with the local community. One of the communal lounges has been adapted as a games room. Service users are able to play pool or table ice hockey. There is also a play station 1, Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 21 The home is with games, as well as a television and video. One service user spoken with during the inspection said she loves the play station, and uses it a lot during her stay at Mill Dale. The home has a selection of videos and DVDs. On the wall of one of the lounge areas is a world map. One of the staff at Mill Dale is currently undertaken a world tour, each leg of the tour is highlighted on the map and service users, relatives and staff are able to monitor her progress. The manager explained that service users and relatives have shown an interest in the staff member’s progress. The member of staff sends a postcard from the different countries she visits. The home is clean and tidy. The laundry facilities at the home are excellent. Service user surveys indicated that the home is always fresh and clean. The manager has arranged for the main lounge carpet to be cleaned as it is stained in places. If this proves unsuccessful the carpet will be replaced. The stains are as a result of service users spilling their cups of tea or coffee. It was agreed that if the carpet is replaced a darker shade would be more appropriate. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A competent staff team supports service users. The home’s recruitment policy and procedure requires some improvement to ensure it is sufficiently robust to protect the service users. EVIDENCE: All six surveys completed by relatives/carers said that they felt there were enough staff on duty and that they were satisfied with the overall care provided. Service users who responded to the survey said that the staff always treat them well and that the carers generally listened to them and acted on what they say. The manager’s philosophy of quality care is based on positive outcomes for service users. And staff are encouraged to participate in training and personal development in order to provide quality client care. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 23 The manager confirmed that 75 of the staff have achieved an NVQ (National Vocational Qualification) level 2 in care. A further 3 staff are currently working towards NVQ level 3. All co-ordinator staff are NVQ assessors. All care staff have either completed or are currently undertaking LDAF (Learning Disabilities Award Framework) accredited training. One member of staff who is new to this service explained that she is currently undertaking training appropriate to her new role. She is finding the training quite challenging but rewarding. Staff records are held centrally. Two inspectors audited a sample of thirteen recruitment records on 28th September 2006. The sample covered thirteen Kirklees Metropolitan Council services and establishments. Records were generally of a good standard. However, three of the files did not have a CRB (Criminal Records Bureau) number recorded to evidence a check had been carried out. Two of those files did not have evidence that a CRB check had been carried out by Kirklees as the employer. Seven files did not include a recent photograph of the member of staff. The manager explained that there has been no new staff at the home, apart from those redeployed for other social services departments. However, any future new staff will undergo induction training in accordance with the common induction framework as set out by “Skills for Care”. The induction training will take place over a four-week period where upon staff will receive mandatory training in accordance with their specific role. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. The health, safety and welfare of service users and staff are promoted and protected. Quality monitoring visits are not taking place. EVIDENCE: Ms Deborah McKay has managed the home since it opened in April 2006. Ms McKay comes from a day centre background and has worked with people who have learning disabilities for over 15 years. She is due to leave her post as manager in early December 2006. To date, the Commission for Social Care Inspection has not been notified of any interim management arrangements until a replacement for Ms McKay is found. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 25 The staff at Mill Dale spoke positively about Ms McKay’s management style and said that she has brought knowledge and enthusiasm to this developing service. Every effort should be made in finding a replacement for Ms McKay as soon as possible. It was clear from speaking with staff and through direct observation that Mill Dale offers an excellent respite service to people with learning disabilities. The inspector feels that without a manager in place, the hard work, which has already gone into this service and future developments, could be compromised. Excellent progress has been made in introducing a quality assurance system that actively seeks the views of people who are involved in Mill Dale. In September 2006 questionnaires were sent out to service users and their parents/carers. The format used for service users was very user friendly, and included graphics and simply asked questions. The response to both service users and parent/carers surveys was very good. A summary of the findings has been produced and copies of both were displayed in the front entrance of the home. The summary identifies areas of weakness and the action required to ensure these are addressed. In accordance with Regulation 26 of the Care Homes Regulations 2001 it is an expectation that representatives involved with this service, that is Kirklees Metropolitan Council, carry out monthly visits to the home. The purpose of the visit is to speak to service users and staff in order to form an opinion of the standard of care provided in the home. A tour of the home and examination of documents must also be undertaken. Following the visit a report on the findings must be produced, a copy of which must be made available for the purpose of inspection. There were no reports available for examination during this inspection, therefore no evidence that these visits are in fact taking place. The manager and staff make sure that so far as is reasonably practicable, the health, safety and welfare of people living at the home and staff is promoted, by way of appropriate written risk assessments and action to minimize risks. Risk assessments were seen in respect of safe working practices within the home. The manager has just spent a considerable amount of time ensuring all risk assessments were current and up to date. The fire alarm system is tested every week. All staff have undertaken fire training since the home opened earlier this year. A fire drill took place on 29th September 2006 involving 4 staff. The manager must ensure that all staff are involved in a fire drill at least twice a year. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 3 X 4 4 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 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 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 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 4 Standard YA6 Regulation 15 15 15 12 Requirement Each service user must have a care plan in place that is current and up to date. Unless impracticable, the service user must be involved in the care planning process. Unless impracticable, the service user must be involved in the reviewing of his/her care plan. The manager must explore the comments made in surveys to ensure that service users feel they are able to make their own decisions about their lives. Risk assessments must be in place in respect of each service user. Required pre-employment checks must be carried out on all staff. Recruitment records must include a CRB check carried out by the current employer and a recent photograph. Management visits to the home must take place every month. A report on the findings must be produced and made available for the purpose of inspection. All staff must take part in a fire drill at least twice a year. DS0000067159.V309310.R01.S.doc Timescale for action 30/12/06 30/12/06 30/12/06 30/12/06 YA6 YA6 YA7 5 6 YA9 YA34 13 19 Schedule 2 30/12/06 30/12/06 7 YA39 26 30/12/06 8 YA42 23 30/05/07 Mill Dale Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA37 Good Practice Recommendations The CSCI should be informed of the new management arrangements at the home. Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Mill Dale DS0000067159.V309310.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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