Inspection on 24/09/07 for Millstream View

This inspection was carried out on 24th September 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Millstream View 29/04/10

Millstream View 17/09/08

Millstream View 16/08/06

Millstream View 06/03/06

Millstream View 26/10/05

Millstream View 21/02/05

Millstream View 26/08/04

Millstream View 29/05/03

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Millstream View Mill Lane Adwick Le Street Doncaster South Yorkshire DN6 7AG Lead Inspector Ramchand Samachetty Key Unannounced Inspection 24 September 2007 11:00 DS0000032073.V337322.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 DS0000032073.V337322.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. DS0000032073.V337322.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Millstream View Address Mill Lane Adwick Le Street Doncaster South Yorkshire DN6 7AG 01302 721408 01302 729413 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) NONE Doncaster Metropolitan Borough Council Vacant Care Home 13 Category(ies) of Learning disability (13) registration, with number of places DS0000032073.V337322.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users with challenging behaviour can only be accommodated in the 8-bedded unit. 16th August 2006 Date of last inspection Brief Description of the Service: Millstream View is a Care Home registered to provide accommodation, care and support to up to 13 young adults with a learning disability (18-65 years of age). The accommodation is offered within two separate units. One unit, which is located on the ground floor, provides care for up to 8 young adults with learning disabilities and challenging needs. The second unit is located in a part of the building where the accommodation has been arranged into 5 individual and separate flats. Both units have separate access. They each have a dedicated staff group. The Home is situated on Mill Lane, in Adwick-Le-Street village, Doncaster. It is close to local amenities, including shops, a post office, and a church. The ‘Adwick Social Education Centre’ is situated next to the Home, and is attended by the majority of the service users of Millstream View. Millstream View is owned and managed by the Social Services Department of the Doncaster Council. The post of registered manager is currently vacant. The home has produced a statement of purpose, which gives more information about the service it provides. The fees charged, at 24 September 2007, ranged Between £63.95 and £1200.00 a week. The home states that additional charges are made for the following: hairdressing, personal toiletries, newspapers and transport to social events. Further information can be obtained from the home. DS0000032073.V337322.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out on 24 September 2007, starting at 11.00 hours and ended at 19.00hours. The service is registered to provide personal acre and support for up to 13 adults with a learning disability and who have complex and challenging needs. There were 9 people in residence at the time of this inspection. The assistant manager, Ms Laura Bennett was present for part of this inspection. The registered manager had left her post and was working as a part time care officer at the home. All the key national minimum standards for ‘ Care Homes for Adults (18-65) were assessed. The inspection included a tour of the premises, examination of care documents and other records, including those pertaining to staff rota, medicines, complaints and maintenance of equipment and systems. We spoke to three people who live at the home and five members of staff, including the assistant manager. The care of two people was examined in some detail and some care practices were observed. As part of the pre-inspection planning, we looked at the self-assessment document that the provider submitted to this Commission. Comment cards received from people who use the service and their relatives were also considered. Some comments received from people who use the service include the following: ‘ Staff look after me well’ ‘ I am happy here’ ‘ I like going for walks and staff always come with me’ Other views and comments received have been included in this report. What the service does well: People who use the service and who could express their opinion said that they were happy at the home and that staff treated well. There was a good staff team, which worked well together to ensure the continuing wellbeing of people living at the home. Staff were good at supporting people to make choices, take reasonable risks and maintain as independent a life as possible. People living at the home were encouraged to take part in various social activities and to benefit from an active and enjoyable lifestyle both in the home and in the community. DS0000032073.V337322.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The registered provider needs to make sure that all information about the home is made accessible to people who use it. There is a need to improve the procedures for assessing needs of people referred to the home in order to find out whether such needs can be met, before they move in. Individual care planning, including actions to manage risks needs to be improved. Appropriate care records must be kept and they must be used in the review of care provided to individuals. Although, people living at the home have their main meals at the day centre, it is still important for staff to monitor their nutritional needs, in order to assist them in maintaining their health. Staff needs to keep a correct record of all medicines that are kept at the home so that their use can be appropriately monitored. The complaints procedures of the home must be reviewed and updated and needs to be made accessible to people who use the service. This will encourage people to make complaints and therefore assist in service improvement. The level of care staff deployed at the home must be reviewed, in line with the dependency needs of people who use the service. All care staff must be provided with adequate training so that they can do their job well. This should include training on issues of ‘Equality and Diversity’. The service needs to develop effective quality monitoring and quality assurance methods, which will take account of the views of people who use the service and their representatives. In light of the vacant post of the ‘Home manager’ the registered provider needs to make sure that interim management arrangements are put in place promptly and the post be recruited to as soon as possible. DS0000032073.V337322.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. DS0000032073.V337322.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 DS0000032073.V337322.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): 1 and 2. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs were assessed before their admission to the home in order to make sure that such needs could be met. However, the assessment procedures were not robust enough to include all relevant aspects of needs and aspirations EVIDENCE: The statement of purpose of the home was available. Staff stated that it had been revised following advice given at the last inspection. However, no service user guide was available. There was no information about the fees charged by the home. The statement of purpose was still not offered in an accessible form to the people who use the service. There was evidence in the care records that needs of people being admitted to the home were not consistently being assessed before their admission. In one instance, the assessment did not relate to the person’s placement at the home. The home’s assessment procedure was used to complement the social workers’ assessments, but these were too brief and failed to include all relevant needs. Some people who live at the home, who had completed our survey, as part of this inspection, said that they did not get enough information about the home, before they moved in. DS0000032073.V337322.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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home were receiving the necessary care and support from staff. However, areas relating to care planning and its recording and review were rather weak and did not provide satisfactory guidance to staff in their tasks of delivering care. EVIDENCE: The individual care plans of two people who live at the home were examined. They were broadly based on the assessment of needs, in particular the one undertaken by staff. Various aspects of personal, health and social needs were addressed, but not always in a comprehensive manner. This meant that some identified needs were not effectively catered for. In one instance, no action had been planned to address the identified communication and behaviour difficulties relating to one individual. The aspirations and goals of individuals were also not always addressed in their individual plans of care. Care plans were mostly based on daily living activities. There was little evidence that the person-centred approach had been considered in developing care plans. DS0000032073.V337322.R01.S.doc Version 5.2 Page 11 Care plans contained guidance on how identified care needs should be met. However, care provided was not regularly recorded. In a few instances, there was no record that, instructions written in care plans, for example, the need to seek advice on skin integrity of an individual, had been followed up. A similar shortfall was evidenced in the care records and follow up regarding an issue of continence. In both cases staff were unable to confirm that the follow up action had taken place. These shortfalls were, in the main, due to the lack the irregular pattern of recording care that is provided. It was noted that health issues were recorded separately and that on occasions general care issues would also be recorded in that section. However, again, there was no evidence that care interventions were appropriately followed up. The review of individual care plans were carried out but the process undertaken to do the review was not clear. Staff had written that the review had taken place and the care plan remains the same. There was little evidence that the review had involved the individual concerned or their representatives. People who live at the home, and who could express their opinion, stated that staff were helping them to manage their daily activities. They said that they were receiving ‘good care’ from care staff. In discussion with staff and people who use the service, we found out that there were many instances where staff were actively supporting them to make decisions about their daily activities. This included both their main daytime occupation and their social activities. Risks involved in these activities were assessed and managed so that they could enjoy as good a quality of life as possible. However, risk assessments were not specific enough and therefore actions to be taken to manage risks were not always clear. DS0000032073.V337322.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, 15, 16 and 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home were supported in taking part in a range of social activities, which helped them maintain their preferred lifestyle and as good a quality of life as possible. EVIDENCE: During weekdays, people who use the service attend the local day services centre, which is situated next to the home. They undertake various daytime activities with the support of day service staff. If individuals were not able to attend the day centre, the home staff would, in consultation with them, organise activities within the home or in the local community. One person said that he enjoyed ‘going for walks’ with the staff when he had some free time. Others said that staff would accompany them on their shopping trips. DS0000032073.V337322.R01.S.doc Version 5.2 Page 13 People who live at the home also commented that staff would help them decide how to spend their time once they had returned from the day centre and that there were always something to do to keep them occupied. However, there was less information about activities undertaken during the weekends. Records showed that people who live at the home were supported to keep in touch with their relatives and friends. People we spoke to and those who took part in our survey, said that the staff treated them well. They said that they were always listened to. We observed some interactions between staff and people who live at the home. They were based on respect for the individual and issues of privacy and dignity were well addressed. People who live at the home had their main meal at the day centre. They were provided with other meals, mostly uncooked snacks. These included breakfast, an afternoon meal and supper. In discussion, we noted that staff had little information regarding the meals provided at the day centre and therefore had inadequate information on which to monitor the dietary intake of people who live at the home. In addition, the care plans checked showed little evidence that nutritional needs had been adequately assessed. This could lead to poor dietary intake and therefore adversely impact on the health and wellbeing of people who use the service. DS0000032073.V337322.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. This judgement has been made using available evidence including a visit to this service. People living at the home were receiving appropriate personal and healthcare support. EVIDENCE: The care plans that we checked, showed that personal support to people who live at the home, was provided in a way that took their preferences into consideration. A number of people had complex and challenging needs and therefore required a substantial amount of care and support. Care records showed that in general, peoples’ healthcare needs were met. Visits by healthcare professionals and health issues were recorded, together with actions taken and this helped in making sure that the health of individuals were monitored. We noted that only one individual had a ‘health action plan’ in place, and this showed how various professionals were contributing to the health and wellbeing of the person concerned. DS0000032073.V337322.R01.S.doc Version 5.2 Page 15 In discussion with care staff, it was noted that a number of them were very knowledgeable about the specific needs of each individual and the way these needs should be met. However, the individual plans of care and records of care did not include the various aspects of the care and support provided. We observed some interactions between staff and the people who live at the home. It was noted that some individuals were ‘very happy’ in the company of staff. The storage, handling and administration of medicines were checked. Records of medicines received were checked. In some instances, the records were incorrect as the quantity of medicines that remained were not added to that received at each delivery from the chemist. None of the people living at the home were self- medicating. The medicines of people who attend the day centre were packed and sent with them. This allowed the day service staff to help them take their medicines. DS0000032073.V337322.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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information about the home’s complaint and adult safeguarding procedures was available to people who use the service but it was in an accessible form to help them use it. EVIDENCE: The home had use of the corporate complaints procedure of the Doncaster Metropolitan Borough Council. A brochure relating to the procedure called the ‘View point’ was available at the home and people could use it to make a complaint. The statement of purpose also contained information on how to make a complaint. However, very little of the complaint information appeared to be accessible to people who use the service. There had been no complaints about the home in the previous twelve months. Staff said that they were usually successful in dealing with initial concerns in a prompt manner. People who took part in our survey, mostly on behalf of those who use the service, said that they knew who to complain to and they were confident that their concerns would be appropriately dealt with. Adult protection procedures were in place in order to protect and safeguard people who live at the home. These procedures were those of the Social Services Department of the Doncaster Council. The home has developed it own DS0000032073.V337322.R01.S.doc Version 5.2 Page 17 protocol for reporting actual or suspected abuse of people using its service and staff found this helpful. The home had recently invoked this procedure to report an allegation of abuse and this matter is being investigated. It was noted that a number of care staff had not yet received training on adult safeguarding issues and this could affect how well people who use the service are protected. DS0000032073.V337322.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home felt it was comfortable. The home was clean and tidy. However, equipment for assisting people with their bathing required improvement. EVIDENCE: The home was purpose built as a hostel and therefore provided rather large communal areas and industrial type of facilities, in particular the kitchen. It continues to offer accommodation on two floors, and access between them, is provided by stairs only. Parts of the building are not in use by the home. The home is divided into two sections. One section has been organised as ‘flats’ and therefore appears more domestic, with a smaller lounge, kitchen, washing machines and hygiene facilities. The other section has fewer bedrooms and is used for people who have more challenging needs. The DS0000032073.V337322.R01.S.doc Version 5.2 Page 19 communal areas in this section include two lounges, bathrooms and toilets and a large kitchen facility. One of the rooms in this section has been developed to provide some sensory stimulation for people who live in it. One of the bathrooms had a mechanically adjustable bath in order to provide assisted bathing to people who required it. The other bathroom was fitted with a chair hoist. However, it was noted that the hoist was rather small and could only be used comfortably for all those who needed it. This matter was highlighted in the last inspection and has not been addressed. All parts of the home appeared clean and tidy and free from malodours. One of the bedrooms in the ‘flat’ area had been used for storage. It contained a number of furniture and equipment, some of which appeared damaged. It was kept unlocked and therefore could be a safety hazard to people living in that area. Bedrooms were personalised to reflect individuals’ tastes and preferences and people who live at the home said they ‘liked’ their rooms. DS0000032073.V337322.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was a good and competent care team in place and was able to meet some of the complex needs of people who use the service, however, the staffing level was not always adequate to meet their all their identified needs. EVIDENCE: There were nine people living at the home at the time of this inspection. Four of them had complex and challenging needs. At peak times, there were five members of care staff, including the assistant manager who had management responsibility. All the people using the service were attending the day centre. In discussion about the dependency of people living at the home, it was noted that one person needed one to one staff support and another required the support of two members of staff at most times. There was no evidence that this level of care staffing was based on an assessment of the dependency needs of people using the service. DS0000032073.V337322.R01.S.doc Version 5.2 Page 21 We also found that one domestic staff was often allocated care duties. Another domestic also work part-time as a carer. Both members of staff were insufficiently trained to provide care to people with learning disabilities and who have such complex needs. The assistant manager stated that the care hours provided by the domestic staff were necessary in order to meet needs of people at the home. Staff spoken to, said that more care staff were needed, particularly, during the mornings, so that people can be better helped to get ready for their day time activities. The assistant manager stated that the care workers were very helpful in undertaking overtime to cover care duties during staff absences. She also said that on occasions, staff from the adjoining day centre would be deployed at the home to cover such absences. Staff spoken to, said that they had received training on a number of topics. These included moving and handling, fire safety, food hygiene and health and safety. It was noted that about half of the care team had not yet received training on adult safeguarding. In response to a requirement that we made at the last inspection, a number of care staff has now received training on managing challenging behaviours. Staff said that the training had equipped them to give better care to people using the service. Training records showed that six members of the care team had undertaken the ‘Learning Disability Award Framework’ and only eight carers had achieved their ‘National Vocational qualification (NVQ) level 2 in Care. It was noted that none of the staff team had received any training on issues of ‘Equality and Diversity’, although some aspects of the value based approach for people with disabilities were briefly addressed in other courses. In discussion with the assistant manager, we found that there was not enough forward planning for staff training and this could affect the ability of the service to continue meeting the specific needs of people who use it. The home had use of the Doncaster Council’s recruitment and selection policy. This included guidelines on the practice of equal opportunities and of antidiscrimination. Two members of staff had been recruited since the last inspection. Appropriate pre-employment checks had been carried out before they started working at the home. The staff profile at the home did not adequately reflect the diversity of the local population. Just under 20 of the care staff were male. There were only two staff members from the ‘Black and Ethnic Minority’ communities and they were part of the ancillary staff team. This lack of diversity in the staff team could affect the take up of the service and also the way overall needs are met. DS0000032073.V337322.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was a good and committed staff team, which was working well together to provide as good a standard of care and support as possible. However, changes in management of the home and the delay for making alternative arrangements were rather unsettling for staff and also for people who use the service. EVIDENCE: The assistant manager stated that the registered manager had left her post at the beginning of August 2007,and assumed on her request, the role of a partDS0000032073.V337322.R01.S.doc Version 5.2 Page 23 time care officer at the home. This information had not been previously communicated to the local office of the Commission for Social Care Inspection (CSCI). It was not clear what management arrangements were put in place. We found out that the deputy manager was also leaving the home at the beginning of October 2007. There was, however, a senior social services manager who had management responsibility for the home. Staff spoken to, felt they were working well as a team, in order to provide a good standard of care to people using the service. The self- assessment document that was provided for the service stated that staff had undertaken a satisfaction survey of people who use the service. However, there was no evidence that the survey had been undertaken. There were no quality monitoring and quality assurance methods being used at the home. The manager, who has direct line responsibility for the service, was undertaking the monthly unannounced visits (Regulation 26), to the home and reporting on the findings. However, these reports remained very poor regarding the information they contained. A requirement was made at the last inspection for these reports to be improved so that they could act as an effective qualitymonitoring tool. The self-assessment information received from the home indicated that all the equipment and utilities were regularly serviced or tested as recommended by the manufacturer and by other regulatory body. Records confirmed that these checks had taken place. The fixed electrical circuits had been checked in the last three years. (2003). Except for a bedroom that had been used as storage area and that had not been locked, no other hazards were noted. Staff had received health and safety training to ensure that they could work in a safe environment. DS0000032073.V337322.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 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 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 X 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 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X DS0000032073.V337322.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Timescale for action 30/11/07 2. YA20 13 Care planning, including risk management, care recording and the review of care must be improved so that the needs of people using the service can be fully met. The quantity of medicines 30/11/07 received and kept at the home must be correctly recorded so that they can be appropriately monitored. An appropriate and up to date 07/12/07 complaints procedure must be made available to people who use the service, in forms that are accessible to them. All staff must be provided with 14/12/07 training on adult safeguarding policy and procedures. The room used for storage of furniture and equipment must be kept locked at all times, in order to protect people living in that part of the home from potential hazards. The home must ensure that there is suitable equipment in place to assist people who live at DS0000032073.V337322.R01.S.doc 3. YA22 22 4. YA23 18 5 YA24 23 30/11/07 6. YA29 23 14/12/07 Version 5.2 Page 26 the home to have a bath. This includes the provision of a bath hoist of suitable size. (Previous timescale of 30/12/06 not met) 7. YA33 18 The registered provider must review the level of care staff deployed at the home, to take into account the dependency of people living at the home and to make sure that needs can be fully met The registered provider must make sure that only staff recruited and trained as care staff, are deployed as carers at the home, at all times. The registered provider must take steps to make sure the vacant post of manager for the service is filled as soon as possible. Appropriate management arrangements must be put in place in the mean time. 30/11/07 8. YA33 18 30/11/07 9. YA37 8, 12 30/11/07 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 YA1 Good Practice Recommendations The statement of purpose and service user guide should be improved to include all the necessary information, and be made available in forms that are accessible to people who use the service. The home’s procedures for assessing needs of people, who are referred to it, should be improved to cover the various aspects of their care and aspirations. Staff should make sure that nutritional needs of people living at the home are appropriately assessed and that the DS0000032073.V337322.R01.S.doc Version 5.2 Page 27 2 3 YA2 YA17 4 5 YA32 YA35 6 YA39 relevant information about menus of the day centre is sought and used to monitor their dietary intake. The staff team should be provided with appropriate training on ‘Equality and Diversity’ issues. Staff training and development should be appropriately identified and planned ready for each financial year to ensure resources can be accessed in the interest of service improvement. Appropriate and effective quality monitoring and quality assurance methods, which take into account the views of people who use the service, should be developed to assist in service improvement. DS0000032073.V337322.R01.S.doc Version 5.2 Page 28 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. 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