Inspection on 13/09/06 for Montague Drive

This inspection was carried out on 13th September 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Montague Drive 21/09/09

Montague Drive 19/09/07

Montague Drive 17/01/06

Montague Drive 08/06/05

Montague Drive 25/01/05

Montague Drive 27/01/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Montague Drive 20 Montague Drive Leeds West Yorkshire LS8 2PD Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 13th September 2006 09:30 Montague Drive DS0000001482.V303922.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 Montague Drive DS0000001482.V303922.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. Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Montague Drive Address 20 Montague Drive Leeds West Yorkshire LS8 2PD 0113 240 0062 0113 2400062 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) www.c-i-c.co.uk Community Integrated Care Ms Eileen Mary Noland Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: The South Yorkshire Housing Association owns the property at Montague Drive. The care and services are provided by Community Integrated Care which is a registered charity caring for people with special needs. Montague Drive is a detached bungalow located within 2 miles of Leeds City Centre and is at the top of a quiet cul-de-sac. There are a wide range of shops and leisure facilities within easy reach of the property. The home has 4 bedrooms. All are single rooms and have a washbasin. The people living at the home prefer to be referred to as ‘person supported’ or ‘people supported’, therefore these terms have been used throughout this report. Each inspection report publishes the fees charged for each placement but unfortunately this information has not been made available to the people supported or the CSCI. A requirement has been made that this information is provided. Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk A pre-inspection questionnaire was completed by the home and this information was used as part of the inspection process. One inspector carried out a site visit and spent six and a half hours at the home. During the visit the inspector looked around the home, and spoke to the people supported, staff, the new manager and a healthcare professional. Records were looked at including; support plans, risk assessments, healthcare records, meeting minutes, and staff recruitment and training records. What the service does well: What has improved since the last inspection? What they could do better: There were gaps in the care planning process, which has resulted in the needs of the people supported not being satisfactorily met. Because of the lack of information and guidance, staff are using different approaches which has Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 6 resulted in the people supported receiving inconsistent care. There was also evidence that health care needs were not being met. The people supported should be given more opportunities to engage in recreational activities and make decisions about the care they receive. Keyworker meetings are not held regularly and they do not attend team meetings. There was a very unpleasant odour throughout the home. Requirements and recommendations that were identified at this inspection are at the end of this report. 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. Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 7 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 Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 8 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&5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs to review the service provision to ensure the people supported are receiving a service that meets their needs. CIC have not provided a record of the care home’s charges and amounts paid by or in respect of the people they support and this prevents the people supported or their representatives from having access to this information about their placement. EVIDENCE: No people supported have been admitted to the home for nearly nine years, therefore there was very little recent evidence available for many aspects of this outcome group. Each person supported should have been issued with a statement of terms and conditions, and this should identify how much is charged on behalf of each person supported. Terms and condition statements were available in three of the four files but the fees charged on behalf of the people supported was not included. The amount which is deducted from benefits is recorded, for example one statement had the contribution as £107.30 but this does not reflect the amount charged by CIC. The persons supported and the manager did not know how much the organisation charges for each placement and they did not have access to this information. The regulations clearly state this information must Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 9 be available in the home. The pre inspection questionnaire asks for information about the current scale of charges but this was left blank. The home is currently registered to provide care for people with a learning disability between the ages of 18 and 65. One person supported is 55 and two are over the age of 70 and one will be 65 in Feb 07. Therefore the home is providing care to younger adults and older people. Concerns were raised during the inspection that the needs of some people supported were not being appropriately met. These details are documented later in the report. The home is assessed against the national minimum standards for adults between the age of 18 and 65. The organisation should look at these standards and the standards for older people and decide what type of service is most appropriate. An application for a variation must also be submitted to ensure the registration categories accurately reflect the service. The CSCI has written separately to the registered person regarding this matter. The registration certificate was not displayed in the home. A staff member retrieved half of the certificate which had been archived in the garage but was unable to find the other half. Montague Drive DS0000001482.V303922.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, 8 & 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some areas of need have satisfactorily been assessed but there are gaps where needs and risks have not been assessed, therefore some needs are not met. There are not many opportunities for the people supported to make decisions or be involved in the running of the home, which has resulted in limitations of choice. EVIDENCE: Care records for two people supported were looked at. There was some good information in each plan of care and there was guidance on how individual needs should be met. Each person’s abilities to carry out personal care tasks and daily living skills were specific. Risk assessments had been completed for various risks that have been identified. There were some standard assessments, for example risk of scalding from bathing or hot drinks, and then assessments which were specific to their individual needs. Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 11 However, some important information about care needs and risks were not included. One person supported regularly made allegations about members of staff and had done so the day before the inspection. There was no reference to this in the plan of care or risk assessments and it had not been recorded in the daily records. This is poor practice and does not protect the person supported or staff. The manager said staff had regularly liaised with other professionals and had received advice and guidance but this had not been recorded. One person supported is epileptic and information relating to this was at the back of their file, however, there was no information in their plan of care. One person would only eat particular foods. Different staff handled this differently and the plan of care did not contain sufficient guidance on how the person’s needs should be met. Some staff said a key problem that compromised the quality of care was an inconsistent staff approach. A keyworker system is in place but the role of keyworker varies depending on the individual staff and there is no guidance on what the role of a keyworker entails. Each person supported has one keyworker. One person’s keyworker only works nights and another person’s keyworker is bank staff. This obviously limits opportunities to carry out keyworker responsibilities. The manager had identified that this needed reviewing. Each person supported should have monthly keyworker meetings to discuss the care planning process, healthcare needs, activities and any other issues. One person supported had records for a keyworker meeting in January 05 and in June 06. No other information was available. Staff confirmed that keyworker meetings were not being held on a regular basis. There are no meetings that people supported attend. Staff said the people supported could attend team meetings but the meeting minutes confirmed that only staff attended, and on some minutes they were recorded as staff meetings. Montague Drive DS0000001482.V303922.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, 14, 15, 16 & 17 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has gone through an unsettled period and this had led to the people living at the home receiving a less than satisfactory standard of care. The level of stimulation and motivation is poor. The new manager has made some positive changes, which has already improved the standard of care. EVIDENCE: Staff said there had not been regular recreation over recent months, which included in-house activities and outings. Staff also said the vehicle had not been frequently used because there are not many drivers and staffing levels had been a problem. However, they said there had been more opportunities to take people out locally in the last few weeks. The home has a car and people at the home make a financial contribution. Three people each pay £16.50 per week. The inspector asked one person supported about the cost of the vehicle but they were unaware they made a contribution. The transport record was looked at for the last six weeks. There Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 13 had only been a few trips to the GP, supermarket shopping, St Mary’s and the office. There were no leisure outings. One person’s recreation plan of care stated they enjoy pubs, theatre, tea dances, shopping and eating out. Staff said this information was out of date and related to a period when the person supported was more active. The majority of people supported are of a pensionable age, and some choose to lead a less active lifestyle. This should be reflected in the relevant plans of care. A keyworker discussion that was held in June 2006 identified that the person supported should be offered more opportunities to do simple exercise, bake and go out more. There was no evidence to show that any of this had been implemented. One person supported who attends day care said she enjoys this. Other people supported do not attend external day services, although one person has a day care placement but has chosen not to attend. The manager and staff are looking into the reasons why the placement has broken down and whether it could recommence. Daily records confirmed that the people supported who have relatives are encouraged and assisted to maintain and develop relationships. One person supported talked about visiting relatives. Previously the main meal was served at lunchtime but this was not working well, therefore the manager introduced a new system and the main meal is now served on an evening. Menus are also being reviewed. This is only a very recent change, therefore it was too early to fully assess the effectiveness of the changes. Montague Drive DS0000001482.V303922.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 adequate. This judgement has been made using available evidence including a visit to this service. The home provides a flexible service which is based on the wishes of the people living there. However, systems must improve to make sure healthcare needs are met. Medication systems are satisfactory. EVIDENCE: Staff said they did ask the people supported about what they want and offer them choices. Daily records confirmed that bed times and bath times varied. Care practice was observed throughout the day of the inspection and it was evident that staff offered choices to the people supported. This included where they wanted to sit, whether they wanted a bath and what they wanted to eat. Health care records were looked at. One person’s records stated that the only health care appointments that they had attended in 2005/06 were two chiropody appointments. No information relating to GP, dentist, optician or other health care appointments was available. Therefore it was not possible to monitor health care provision. Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 15 One person was complaining about a sore patch behind their ear and asked the inspector to look. The patch was red and inflamed and had a yellow crust. The person supported said it was sore and had been caused by staff not drying it properly. Staff said it was caused by the person rubbing it. There was an entry in the daily record on the 16 August that a ‘yellow waxy substance was behind the ear’ and there were entries after that date that referred to the sore. Staff had not arranged for the person supported to see a GP about it. This is poor practice. One person said they were unable to get into the home’s car. Staff said they could if they focussed on the task but acknowledged that the person had lost some mobility over a period of time. The transport records did not contain sufficient information about passengers therefore it could not be established when the person supported last travelled in the vehicle. However, staff thought it was quite some time. Concerns were raised during the inspection that some care needs were not being appropriately met. The organisation must look at their service provision and decide if the home can meet the needs of all the people supported. This should be done through a formal assessment process and health care professionals should be involved. Areas of need that should be assessed to ensure the people supported are receiving the right type of care include mobility, continence, epilepsy and dementia. The manager had identified that there should be more input from health care professionals and had started going through the areas where this would be relevant. Referrals had been made to various agencies and some healthcare professionals had started the assessment process. During the inspection, a health care professional visited the home to assess the needs of one person supported, they stated that there had been recent improvements and health care advice had been followed. Weight records for 2006 were blank. Medication records were looked at and were completed correctly. Staff that administer medication complete a medication training course. There was evidence that people’s medication is reviewed with the GP. Montague Drive DS0000001482.V303922.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 adequate. This judgement has been made using available evidence including a visit to this service. Satisfactory procedures are in place but a complaints record is not maintained, therefore it is not possible to monitor complaints from the information that is available in the home. The organisation do monitor complaints. People supported are safeguarded from abuse. EVIDENCE: The pre inspection questionnaire stated that the home has a complaints procedure and one complaint had been received within the last twelve months. No information about the complaint was available in the home. The regulations state that a record of all complaints must be kept in the home. The area manager visits the home every month and monitors complaints as part of her visit. Staff have attended adult protection training and the home has an adult protection procedure. Financial records were looked at. All financial transactions are recorded and receipts are obtained for any purchases made. The people supported have individual bank accounts. Montague Drive DS0000001482.V303922.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, 26, 27, 28 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is pleasant and homely but there is an offensive odour, which is noticeable throughout the home. The systems for infection control are not satisfactory and there is a risk of spreading infection. EVIDENCE: The inspector looked around the home. It was clean and tidy although there was a very strong odour which was unpleasant. Generally the décor was satisfactory. Bedrooms were personalised and each room had a lot of items that reflected individual preferences. For example one person liked certain celebrities and there were pictures and memorabilia in their room. Photographs of family and friends had also been mounted on the wall. This is good practice and demonstrates that everyone is encouraged to make their rooms homely. The people supported were very comfortable and relaxed in their environment and were seen to wander freely around the home. There were pictures and ornaments in communal areas which helped create the homely environment. Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 18 Appropriate hand washing facilities were not available in the home. In the laundry there was a sink but no hand soap or paper towels. In some areas bars of soap and hand towels were provided but these are not appropriate for infection control. The washing machine did not appear to have a sluicing facility or disinfecting programme. Montague Drive DS0000001482.V303922.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): 33, 34 & 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The people living at the home have been disadvantaged because they have not been supported by an effective staff team. Lack of management and a substantial use of agency staff have been the fundamental causes of the problem. Staff have attended regular training but there has not been adequate fire safety training, therefore staff may not have basic fire prevention knowledge. It was not possible to confirm that a satisfactory recruitment process was in place. EVIDENCE: The inspector spoke to all staff on duty and the new manager. Everyone acknowledged that the home should improve the quality of the service. Concerns were raised that everyone was not working consistently and there was not a team approach. During the last few months there have been staff vacancies, which has resulted in different agency staff working at the home. For the six-week period before the inspection, which corresponded with school holidays, there had been a high proportion of staff on annual leave. This was unusual and had resulted in a higher percentage of agency staff working at the home. Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 20 One staff member that recently started work at the home talked about the recruitment process, and confirmed they had attended an interview and completed the relevant forms. Records for two staff were looked at. One file had an application form, confirmation of a criminal records check and proof of identification but only one reference was available. The other file had no application form, references or confirmation of a criminal records check. The manager said copies were kept at the home and originals were held at the organisation’s head office, and it was possible that all information had not been copied and sent to the home. The pre inspection questionnaire stated all staff have attended mandatory training which included moving and handling, food hygiene, health and safety and fire safety. Individual training records are maintained for all staff. The records confirmed that generally regular training has been provided but some staff have not attended any form of fire training and others have not attended since 2004. Two staff have completed NVQ level 2 and two staff are in the process of completing the award. The manager has completed NVQ level 3. Montague Drive DS0000001482.V303922.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, 40, 41 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service delivery has deteriorated because the home has not been properly managed. The new manager has started to make improvements and has a clear vision of what she wants to achieve. EVIDENCE: The last inspection identified that some management tasks were not up to date and the manager had some ‘catching up to do’. This inspection identified that the home had again gone through a period without a manager and as a result the quality of care had deteriorated. Staff who had worked at the home throughout this period said they thought that the people supported had lost out and changes in their behaviour reflected this. A regulation 26 visit from the beginning of August confirmed that these views had been passed on to the service manager. All staff and the manager said they did not think the home was currently providing a satisfactory service and although they were optimistic the new Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 22 manager was making a difference and introducing positive changes there was a lot of work to do. The manager has identified many issues at the home and talked about action that has been taken to start addressing some of the problems. These discussions were very positive and the manager demonstrated a good understanding of the problems and issues within the home. She also had a strong ethos to involve people living at the home, staff and other professionals. Regulation 26 visits were available in the home and identified that some issues had been raised with the management. Copies of the reports have not been sent to the CSCI. The pre inspection questionnaire stated that policies and procedures are available and regular maintenance and health and safety checks are completed at the home. Montague Drive DS0000001482.V303922.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 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 1 STAFFING Standard No Score 31 X 32 X 33 1 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 1 2 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 1 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 3 X 2 X 2 3 3 3 X Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 24 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 YA5 Regulation 17 Requirement Timescale for action 30/11/06 2. *RQN 3. YA6 Care Standards Act; Section 28 15 The registered person must ensure service user plans identify how personal health and social care needs should be met. 12 The registered provider must ensure a record of the current range of fees is kept in the home. The registered person must 31/10/06 ensure the registration certificate is displayed in the home. 30/11/06 4. YA7 5. YA9 6. YA13 The registered person must 30/11/06 ensure the people supported have opportunities to make decisions about the care they are to receive. 13 The registered person must 30/11/06 ensure risks to the people supported are identified and so far as possible eliminated. This relates specifically to the risk from allegations which is detailed in the main body of the report. 12, 16, 17 The registered person must 30/11/06 review the arrangements for the home’s vehicle. This must include opportunities to access the vehicle and financial DS0000001482.V303922.R01.S.doc Version 5.2 Page 25 Montague Drive 7. YA14 16 8. YA19 12, 17 9. YA19 14 10. YA22 17 arrangements. The people supported or their representatives must be involved in this process. The registered person must ensure the people supported have opportunities to engage in appropriate recreational activities. The registered person must ensure the health care needs of the people supported are met. This relates to making sure the people supported access GPs and other health care professionals at appropriate times. Records must be maintained of health care appointments and people’s weight to enable monitoring to take place. The registered person must assess the needs of the people supported to ensure the home is suitable and can continue to meet their needs. This process should involve other professionals as appropriate. The registered person must ensure a record of complaints is maintained in the home. The registered person must take action to address the offensive odour. The registered person must ensure systems are in place to control the spread of infection. This relates to hand washing facilities and the washing machine. The registered person must confirm in writing that the washing machine has suitable disinfecting/sluicing programmes. The registered person must ensure that at all times suitably experienced persons are working at the care home in such DS0000001482.V303922.R01.S.doc 30/11/06 31/10/06 30/11/06 30/11/06 11. 12. YA30 YA30 16 13 31/10/06 30/11/06 13. YA33 18 31/10/06 Montague Drive Version 5.2 Page 26 14. YA34 19 15. 16. YA35 YA37 23 9 numbers as are appropriate for the health and welfare of people supported and the use of any persons on a temporary basis at the care home will not prevent people supported from receiving such continuity of care as is reasonable to meet their needs. The registered person must ensure the home carries out a thorough recruitment process This relates specifically to obtaining staff records and making them available at the home. The registered person must ensure staff receive appropriate fire prevention training. The manager must be registered by CSCI. (A timescale of 01/04/06 was identified at the last inspection but since that time there has been a change in manager.) The registered person must ensure the copies of the regulation 26 reports are sent to the CSCI. The registered provider must provide an improvement plan for the home. 30/11/06 31/10/06 31/12/06 17. YA39 26 30/11/06 18. YA39 24 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. Refer to Standard YA8 Good Practice Recommendations The people supported should be able to attend house meetings or have some avenue that enables them to be involved in the running of the home. Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Montague Drive DS0000001482.V303922.R01.S.doc Version 5.2 Page 28 - 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!