Inspection on 10/10/07 for Nationwide Community Care Limited

This inspection was carried out on 10th October 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Nationwide Community Care Limited 07/10/08

Nationwide Community Care Limited 27/10/06

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Nationwide Community Care Limited 35 Mede Way Wivenhoe Colchester Essex CO7 9HW Lead Inspector Pauline Dean Unannounced Inspection 10th October 2007 09:55 Nationwide Community Care Limited DS0000066756.V352835.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 Nationwide Community Care Limited DS0000066756.V352835.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. Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nationwide Community Care Limited Address 35 Mede Way Wivenhoe Colchester Essex CO7 9HW 01206 828011 01206 824972 medeway_manager@communitycaregroup.co.uk www.nationwidecommunitycare.co.uk Nationwide Community Care Limited 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) vacant post Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability 27th October 2006 Date of last inspection Brief Description of the Service: 35 Mede Way is a compact two-bedroom bungalow situated in a residential area of Wivenhoe, near Colchester. The property has been adapted to accommodate two adults with learning disabilities. Each bedroom has separate en suite facilities. Communal areas include a lounge/dining room and a fitted kitchen with laundry facilities. There is an office/ staff room with sleep-in facilities and a staff toilet. To the rear of the property are a patio area and a compact garden. There is a small area for parking in front of the property and ample parking in the surrounding roads. The service supports younger adults with complex needs to live in an ordinary home environment. Information about the service may be obtained by contacting the manager. The home charges £1,700 a week. This information was given to the Commission in December 2007. Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of 35 Mede Way took place on 10th October 2007 over a seven-hour period. The inspection involved checking information received by Commission for Social Care Inspection (CSCI) since the last inspection in October 2006, looking at records and documents at the care home and talking to the acting manager, care staff, relatives visiting the home and the people living at the home. In addition the Annual Quality Assurance Assessment (AQAA) completed in July 2007 by the previous acting manager was considered as part of the inspection process and a tour of the premises was completed at the visit to the care home. The Responsible Individual for the company came into the home during the inspection. Surveys were sent or left with the home for distribution to the two people living at 35 Mede Way and relative surveys were sent to the family of service users. However, at the time of writing this report, none had been completed and returned to the Commission for Social Care Inspection (CSCI). What the service does well: What has improved since the last inspection? What they could do better: Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 6 Evidence of in-house activities and stimulation is required, for it was not evident either through observation or record keeping what interests and activities the two people living at the home enjoy whilst they are at home. The need to ensure that all gaps in the employment history of all staff are explored was raised at this inspection. The home continues to require permanent consistent management and further recruitment is required to ensure that the home has a full compliment of permanent staff. An established staff group with a training and development programme in place which highlights individual training needs such as communication skill training is needed. A quality assurance system has been introduced. However a quality monitoring system needs to be developed to ensure that the home is working towards meeting the aims and outcomes of the people living at the home. 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. Nationwide Community Care Limited DS0000066756.V352835.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 Nationwide Community Care Limited DS0000066756.V352835.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. 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. The documentation available ensures that the people who come to live at the care home have the information they need to make an informed choice about where to live and their needs are met. EVIDENCE: Both the Service Users Guide and the Statement of Purpose have been updated to reflect the changes to the premises i.e. a reduction from three bedrooms to two bedrooms since the last inspection. In addition, the position of registered manager is now vacant and this has been noted in both the Service Users Guide and the Statement of Purpose. The care service has an acting manager in place. These documents provided appropriate information to ensure that prospective service users and their representatives have sufficient information about the service to make an informed choice when moving into the home. Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 9 The pre-admission assessment and process for the two people living at the care home was considered and inspected. A transitional plan had been created using graphics to plan and programme the move into the home for one of the people living at the home. We were informed that prior to moving in a lengthy admission process had taken place, with input from family and representatives. This was evident from the paperwork seen for each admission and was confirmed by relatives visiting on the day of the inspection. One person living at the care home had entered the home with a detailed care plan and an information file. An Enhanced Care Planning Assessment acompanied this person as they had come to live at the home. Evidence was seen of reports and planning for one of the admissions and the implementaion of boundaries had been discussed when there is inappropriate behaviour. Time limits and planned action has been agreed upon with both the individual living at the home, their Care Manager and the Acting Manager. Nationwide Community Care Limited DS0000066756.V352835.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 & 9. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning documents were comprehensive detailing health, personal and social care needs. Regular reviews were in place to ensure that the people who use the service receive the care they wish and require. Risk assessments enable the people living at the care home to take manageable risks. EVIDENCE: Both people living at the care home have entered the home since the last inspection. One person had entered the home in April 2007, with a detailed and gradual admission process completed. A care plan had been developed with a pen portrait detailing the individual’s personal information. An assessment of physical care needs had been completed with an assessment of Manual Handling covering the person in bed, sitting up, walking, bathing and in Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 11 a wheelchair. This had been created on admission and had been updated on 10/10/07. In addition a service user handling assessment form covering activities and mobility was in place. Maketon is used in communication for one person living at the care home and this was detailed in their care plan. Support plans were in place for choosing clothes, management of continence, choosing menus – eating little and often, dietary needs, drinking, dressing and emotional needs. A daily diary was in place to communicate with this person’s family and an Occupational Therapist had offered input and the home was looking into a multi-sensory input regarding oral hygiene and personal care and support in the kitchen. These had monthly support plan reviews. A second care plan file for the other person was inspected. This person had only been at the home for one month and their care plan was still being developed. Six care plan objectives as had been set at the person’s previous care setting were in place with ongoing amendment and revision to ensure that these meet the care needs of the individual. Basic assessments entitled Practical Independence Assessments are being completed and these cover the individual in the home, their clothes & laundry, money & finances, clinical assessment, mobility, health & safety assessment and travel assessment. It was evident from the work completed that this person was assessed as independent in many of the tasks. Risk Assessments and Management Strategy as had been developed at the person’s previous care setting were seen on file and we were told that these are being reviewed and developed in their care plans. Within both care plans and record keeping there was evidence of the people living at the home being able to make decisions about their lives. This was observed at the site visit, when one person decided to go out and following some discussion and advice a decision was made as to what they would do. A weekly planner was in place for one of the people living at Mede Way. A copy was on file and to be found in their bedroom. Picture symbols are being introduced into this plan to make for easy reading. Daily Progress Notes were seen for each service user, with details of outings noted on each file. Records of behaviour and outings alone were noted and records of disengagement were seen on one file. The records for the other person living at the care home focussed on events important to them. These included the sleeping pattern of the individual and managing challenging behaviour. Whilst outings and trips out with family and friends were noted, there was no information about the activities that this person engaged in at home such as watching TV and DVDs and doing a jigsaw. Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 12 As stated above risk assessments had been considered and implemented for both people living at this home as they entered the home. The acting manager said that these are being reviewed and revised as they get to know the resident. This was evidenced by the detailed assessment and action planning for the most recent admission to the home. Nationwide Community Care Limited DS0000066756.V352835.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. 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. The daily routine and activites in the home were flexible and optional, with people who live at the home being encouraged to make choices with regard to their social, cultural, religious and leisure activities. Family contact and visiting arrangements were open and relaxed, with family links encouraged and promoted. Links with the local community are encouraged and promoted. Overall the care home provides a varied and healthy diet that the people who live at the home enjoy. EVIDENCE: Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 14 Currently both people living at Mede Way continue to take part in activities they engaged in prior to moving into the home. Neither of them has employment nor attends educational or training courses. One person has regular contact visits and outings with relatives and this is programmed into their daily activity programme. The Annual Quality Assurance Assessment stated that the home would ‘provide activities according to the service users’ choice’. ‘Meet regularly to determine and evaluate these choices’. ‘Introduce more variety according to their needs and choices’. Whilst these are valued concepts, there was no information as to how they were going to met these ideals. As stated prviously there was no information about the activities that the people living at the home do in the home such as watching TV and DVDs and doing a jigsaw. One person living at the care home was able to use local public transport, going into Colchester on the bus and going to the cinema. They also used the rail service to visit local towns and London. As stated earlier, one of the people living at the care home had regular visits and outings with their relatives. The acting manager said that this was encouraged and welcomed. At the inspection, two relatives were spoken to and they confirmed that they were kept fully informed and involved in the care of their relative. The rights of the individuals living in the home were seen to be respected. One person was awaiting a letter and they were informed that when it arrived they would be given it to open it. Menu planning and shopping for one of the people living at Mede Way was established and in place. Menus are planned for three days and this food is then purchased. Daily food and drink monitoring charts are kept with records kept of food eaten and any eating and drinking disorders noted. The menu planning and food shopping for the second person living at the home still needs to be planned. No records were available to ascertain whether this person was offered a healthy diet. On the day of the inspection, this person chose to eat out. The acting manager said that care staff are encouraged to sit and each with the people living at the care home. The home has incorporated the document – ‘Safer Food Better Business’ (SFBB) into their food safety documents and they have completed the SFBB manual. Records were kept of the fridge and freezer temperature. These were set at the correct levels. Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 15 Nationwide Community Care Limited DS0000066756.V352835.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 & 20. 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. Overall, the home’s arrangements for supporting the healthcare of the people living at the home was sufficiently detailed to enable staff to know what action is required and what action is to be taken. EVIDENCE: From observation the people who live at the home are able to make choices with regard to clothes, time for getting up and going to bed. This was detailed in their care plan and seen at the inspection. As stated in the Annual Quality Assurance Assessment privacy has been considered and is respected. An example of this was an illuminated alert sign which had been installed above the bedrooom door of the room of the person who is profoundly deaf to alert them of a carer wishing to enter their room. Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 17 The acting manager said that she is a trainer in Maketon and one member of staff confirmed that they are currently undertaking this training. However, relatives spoken to raised concerns that not all staff were able to communicate with their relative who is profoundly deaf. Evidence was seen on the files of the people living at the care home that they are given support and assistance as needed to access health care professionals. Within the Annual Quality Assurance Assessment the home was said to be ‘proactive in using primary care facilities’ and this was confirmed by the acting manager. Evidence of visits to GPs were seen on file and records kept of the action to be taken. In addition the in-house services of a chiropodist has been sought and support is given for out-patient appointments. The administration, storage and dispensing of medication was inspected at the visit to the home. One person living at the home was not taking any medication. Medication for the second person was held in a wall storage cabinet installed in the office. The acting manager said that the home is does not have any controlled drugs in the home. Medication stores and record keeping was found to be in good order. A good practice recommendation was made that the home should hold a record of signatures and initials of staff who give medication. The acting manager said that four care staff have completed a Boots the Chemist medication training course in June 2007. Following this inspection the Commission for Social Care Inspection (CSCI) was informed that this is a competence-based course. Nationwide Community Care Limited DS0000066756.V352835.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 & 23. 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 care home were well treated and listened with complaints and adult protection procedures in place. EVIDENCE: Nationwide Community Care has a complaints and concerns protocol in place. This was inspected at the site visit. The acting manager acknowledged that there is a need to review and revise this document to fully detail the role of the Commission for Social Care Inspection (CSCI) with regard to complaint investigations. The acting manager was informed that it is not the role of the Commission to investigate complaints, but to review the management of complaints and their investigations through regulation and inspection of the care service’s complaints procedure. There has been one formal complaint in the last year and the care home has taken advice and guidance from Colchester Borough Council regarding managing noise. The acting manager said that the home was looking towards ways that they could manage this problem in the home. Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 19 Nationwide Community Care had developed adult protection policies in 2005. These had been revised and updated to reflect current practice and detail the local authority referral procedure. The acting manager said that adult protection training had been booked for 8th and 9th November 2007 and each member of staff is expected to complete and sign annually a declaration regarding criminal convictions. The Annual Quality Assurance Assessment gave very little detail regarding what the care home did well to manage concerns, complaints and protection. It stated ‘Policies in place. Staff attend training in relation to Vulnerable Adults. Service User has a copy of the complaints procedure. Encourage advocacy support’. One member of the care staff spoken to at the visit to the home said that would raise any concerns they had with the home’s manager and/or Social Services. They had a good understanding of Safeguarding Adults procedures having in their previous employment raised concerns under the Protection of Vulnerable Adults (POVA), now Safeguarding Adults. Nationwide Community Care Limited DS0000066756.V352835.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 & 30. 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. The home provides a homely, comfortable and safe environment for service users, which was kept clean and hygienic. EVIDENCE: At the visit to the care home a tour of the premises was conducted. It continues to be well maintained throughout. Within the home there were good quality, modern domestic furnishings and fittings and the décor was in good order. The lounge and dining room was in the centre of the bungalow and offered a comfortable sitting and dining area. There was no television in this room. Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 21 One of the bedrooms had been re-decorated to the individual’s liking and from speaking with relatives of this person it was evident that they too had had some in put into furnishing the room. A lounge area had been created and further changes are planned to enhance this area. This person had a fridge in their room to hold their personal drinks and confectionary. This bedroom had an en-suite shower room and ramp access to the rear enclosed garden. A second bedroom had been enlarged and the third bedroom had been removed. This second room comprised of two rooms, one was a lounge area and the second was the bedroom. The existing walk-in shower and assisted bathroom have been incorporated into this room. The acting manager said that the home was considering dividing this room, thus ensuring that both residents have access to a bath. At the site visit, the two relatives visiting the home were aware of this proposal and felt that it would be positive for their relative living at Mede Way. On the day of the visits there were no unpleasant odours and the home was clean. The laundry facilities are clean and appropriate for the size of the home. The kitchen is a modern domestic fitted kitchen and is clean and well maintained. Nationwide Community Care Limited DS0000066756.V352835.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. 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. Staff were roistered in sufficient numbers to ensure the people who live at the care home are safe and their individual needs are addressed. The care home is developing a permanent staff team to provide consistency and security for the people living at the home. EVIDENCE: Staff rotas detailed two staff on duty between 07:00 to 15:00 hours, one staff member on duty 14:45 hours to 18:00 hours with two staff on duty from 18:00 hours to 22:00 hours. At night there was one awake and one asleep carer. The acting manager said that each service user had a number of designated 1:1 hours, that is 30 hours and 17.5 hours. These hours are managed by the home and there is no external additional staffing allocation. They said that Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 23 the home is currently looking to recruit two more carers and continues to use agency cover. However, the home was now said to have five permanent staff, of whom three have a National Vocational Qualification (NVQ) level 2 in care. The acting manager was advised of the need to detail their hours in the home identifying management and care hours. Overall the staff recruitment procedure and practice was in good order and well managed. Two staff files were sampled and inspected at this inspection. The one shortfall found was that one file did not have sufficient detail to enable the employer to explore the person’s employment history. They had given only the year of employment, not the month or day. One staff file sampled had evidence of an induction training record, however, this had been started in August 2007 and had not been completed. The second staff file sampled was for a carer who had commenced work earlier in the year and there was no evidence of structured induction training or a training and development programme for each individual member of staff. On the staff files there was some evidence of training completed prior to commencing employment at the home and both care staff had completed a NVQ level 2 in care. The acting manager said that Manual Handling, First Aid, Fire Safety, Basic Food Hygiene and Health & Safety courses have been booked for November 2007 and the home will be linking with the company’s other two care homes to access this training. Nationwide Community Care Limited DS0000066756.V352835.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 & 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. People who live in the care home should expect to live in a home that is well run, with a manager who has the skills and has the competence and qualifications to run the care home. People who use this service do not benefit from a developed quality assurance and quality monitoring system. People who use this service can expect their health, safety and welfare to be promoted and protected. Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 25 EVIDENCE: Nationwide Community Care is still without a registered manager at this care home. In the two years since registration there have been five changes in manager. The current manager was the original acting manager, leaving to take up another role in the company. They have returned to take on this role in the interim. The acting manager spoke of the difficulties the company had had in selecting the right person for the post and said that the company was reviewing the current recruitment processes to ensure that the right person is appointed. Nationwide Community Care has developed a Quality Assurance policy, which incorporates service user involvement, family involvement and a continuous improvement plan and training. Survey work had commenced and the acting manager said that the home was looking to developing this quality assurance process to incorporate other stakeholders including relatives. This still needs to be processed. Within the Annual Quality Assurance Assessment (AQAA) the care home states that they would like to review their Quality Assurance Policy/Procedure and Quality Assurance tools, to review, monitor and develop the service. Safety certifications and reports were sampled and inspected at the visit to the home. A gas safety record and service maintenance certificate was seen dated April 2007 and January 2007 respectively. A periodic electrical systems check had been completed April 2007 and electrical equipment checks (PAT) had been completed May 2007. Current certification was seen for the fire alarm system, extinguishers and emergency lighting. This was completed in July 2007 and the Essex Fire and Rescue Service had completed an inspection in July 2007 when fire risk assessment documentation had been completed. Nationwide Community Care Limited DS0000066756.V352835.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 2 X X 3 X Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 27 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation Requirement Timescale for action 19/12/07 2. YA35 3. YA37 19,Schedule People who use the service 2 (5) must be safeguarded by thorough recruitment practices and procedures, namely the gaps in the employment record are explored. 18(1)(c) People who use the service must be assured that they are safeguarded through the introduction of induction training and a training and development programme for all staff. People who use the service 8(1), must be assured by the 9(1)(2)(i) appointment of a registered manager who will have the qualifications, skills and experience necessary for managing the care home. This is a repeat requirement from the last inspection. Timescale 30/06/07 19/12/07 19/02/08 Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc 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. 2. 3. 4. 5. Refer to Standard YA12 YA18 YA20 YA32 YA39 Good Practice Recommendations There should be clear evidence of in-house activities and pastimes encouraged and supported by care staff in the home. People who use the service should be assured that their needs are met with staff attending specialist training as is required to meet their needs. There should be a record of all staff initials and signatures of staff that are administrating medication. The manager’s duty hours must be planned and recorded within the home. People who use the service should be assured that their views and opinions are listened to and acted on through the development of the home’s quality assurance system. Nationwide Community Care Limited DS0000066756.V352835.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Colchester Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Nationwide Community Care Limited DS0000066756.V352835.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. 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