Inspection on 26/05/06 for New Hutte Lane, 9

This inspection was carried out on 26th May 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

New Hutte Lane, 9 10/04/07

New Hutte Lane, 9 20/02/06

New Hutte Lane, 9 18/08/05

New Hutte Lane, 9 24/01/05

New Hutte Lane, 9 02/08/04

New Hutte Lane, 9 02/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 New Hutte Lane, 9 9 New Hutte Lane Halewood Liverpool Merseyside L26 9UD Lead Inspector Daniel Hamilton Unannounced Inspection 26th May 2006 10:00 New Hutte Lane, 9 DS0000021495.V295736.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 New Hutte Lane, 9 DS0000021495.V295736.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. New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service New Hutte Lane, 9 Address 9 New Hutte Lane Halewood Liverpool Merseyside L26 9UD 0151 291 9139 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) Brothers of Charity Mr John Colin Neary Care Home 3 Category(ies) of Learning disability (3) registration, with number of places New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users to Include up to 3 (LD) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 20th February 2006 Date of last inspection Brief Description of the Service: 9 New Hutte Lane is a detached bungalow, which is situated in the Halewood area of Liverpool. The property is owned by ‘Brothers of Charity’, a Registered Charity, which is also registered to provide personal care and support to the three services users who have severe learning disabilities. All three service users moved to the home following the closure of a long-term institution some time ago. The home is spacious and has a lounge, dining area, kitchen, bathroom, wet room / shower area, four bedrooms (one is used by staff for administration and sleeping in duties) and a garden. The garden is adapted for Service Users who have physical disabilities and visual impairments. A purpose adapted mini bus is available for outings and appointments. The Care Home Fee is set at £1062.00 per week. New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted a total of 7 hours. Three service users were living in the home at the time of the visit. At the time of the visit the home did not have a Registered Manager in post. The Organisation (Brothers of Charity) had appointed a new acting manager who was in the process of applying to register with the Commission. The acting manager demonstrated a positive attitude to her role and a commitment to developing the service provided. A tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The acting manager, two staff members and an advocate was spoken with during the inspection. Time was spent with each of the service users following their return from day centres and individual activities. Service users were encouraged to participate in the inspection process using their preferred methods of communication. What the service does well: The home provided a warm, caring and relaxed environment for the service users. Staff were observed to be attentive to the needs of the people living in the home and service users appeared relaxed and happy in their home environment. The home had established a care plan system to ensure the individual needs, preferences and capabilities of service users were identified and planned for. This information was very important because none of the people living in the home were able to communicate verbally. Health care needs were well managed and records showed that service users had access to heath care professionals as required. The home provided staff to a ratio of two staff to three service users. The staffing level is increased at times according to the daily activities and / or needs of each service user. Staff spoken with demonstrated a sound awareness of the needs of the service users and had a positive attitude towards their role and responsibilities. Service users were supported by staff to make decisions and choices within their individual capacities and to take responsible risks as part of their day-today lives. Risk assessments had been completed to control any risks or hazards. Direct observation, examination of records and photographs and discussion with staff confirmed that service users had access to a range of activities both within and outside the home. Activities included the development of New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 6 independent living skills, for example, making beds and looking after personal care. Support staff spoken with were able to give examples of how they promote the rights of the service users. Staff were seen to treat service users with respect, privacy and dignity during the visit. An advocate spoken with reported that the service users were “Very well cared for” and that “I can go to the home anytime I want.” Records showed that no complaints had been made since the last visit and an advocate reported that the organisation was prepared to listen and act upon complaints quickly. Staff spoken with had received guidance on abuse awareness and had completed training on how to protect vulnerable people from abuse. Staff were able to demonstrate a good understanding of the different types of abuse and how to safeguard service users. Training records showed that staff had access to induction and ongoing training to develop knowledge and understanding in a range of areas. Staff spoken with had a good knowledge of the principles of care, health and safety issues and how to promote equality and diversity in the service. What has improved since the last inspection? What they could do better: Records of community-based activities had not been kept up-to-date for one service user and menus viewed did not provide information on deserts. These records should be updated to provide complete information on the individual lifestyles experienced in the home. Medication Administration Records did not provide an audit trail as the details of medication entering the home had not been recorded. Furthermore, New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 7 Medication Administration Records had not always been signed to confirm medication had been administered. This practice is not safe and must stop. Although there was evidence that the home undertakes Health and Safety Audits and takes a serious approach to Health and Safety matters, a safety certificate for the electrical wiring could not be located. This issue must be addressed to confirm that the service users are living in a safe environment. Records of hot water temperature checks in the bathrooms should also be periodically checked, to confirm the temperature is regulated to 43°C. Overall, the home was well maintained to a good standard however, some parts of the home were in need of minor repair / redecoration. These matters should be addressed as soon as possible, to ensure the home remains comfortable and homely for all the service users. 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. New Hutte Lane, 9 DS0000021495.V295736.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 New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Information on the home including the terms and conditions of residency had been developed. This enabled service users and / or their representatives to make an informed choice about whether to move into the home. Assessments of need had been undertaken, to ensure individual needs were identified. EVIDENCE: No new service users had moved into the home since the last inspection. All three service users had lived in the home for a number of years. Each service user’s personal file contained a copy of an original ‘Community Nursing Assessment’, which had been completed before each resident moved into the home. The Registered Provider (Brothers of Charity) had developed a new ‘Statement of Purpose’ and ‘Service User Handbook’ which contained key information on the service provided. The information had been designed with pictures, signs and symbols to ensure the format was geared towards the needs of people with learning disabilities. ‘Contract of Agreement’ documents were available for each service user. New Hutte Lane, 9 DS0000021495.V295736.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 and 9 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. Individual plans were in place that reflected service user’s needs and personal goals. The people living in the home were empowered and supported to make decisions and choices within their capacity. Service users were encouraged to take responsible risks within the context of a risk assessment framework. EVIDENCE: The personal files of the three people living in the home were viewed. Each file contained an ‘Essential Lifestyle Plan’ and ‘Private Plan’. Plans seen were well constructed and provided clear information on the needs of service users and the assistance required from staff to ensure individual needs were met. Each plan had been kept under regular review and updated as required. Records showed that the home worked in partnership with other relevant health care professionals, subject to need. Supporting documentation including; pen pictures, risk assessments, total communication and daily routine plans, learning logs, daily reports, activity sheets, incident and accident records, health care records, personal records and general correspondence was also in place. New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 11 Staff were observed to communicate effectively with the people living in the home and demonstrated a good awareness of the needs, preferred routines and preferences of service users. Staff spoken with reported that they monitored and observed the body language of service users closely, in order to determine needs and choices, as the people living in the home did not communicate verbally. Service users were encouraged to take appropriate risks associated with the normal aspects of daily life whenever possible. Appropriate action was taken by staff to minimise potential and actual risks and service users had access to staff support at all times. A range of individual risk assessments had been completed for each service user to address environmental, health and safety and personal risks. Risk assessments had been kept under regular review. New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. The service users living in the home were encouraged to lead fulfilling lives by participating in meaningful activities, engaging in community life and maintaining appropriate relationships. EVIDENCE: Discussion with staff and examination of care plans and activity records confirmed that two of the service users attended a day centre each week and participated in a range of activities with their peers. Records showed that service users had taken part in various leisure and recreational activities including; swimming, bowling, football, social events and visiting places of interest. One service user also had a ‘Community Partner’ who assisted a service user to access the community and participate in various activities. One service user did not interact as well as the other people living in the home and this continued to limit the options and choices available. There was no record of community-based activities from 1/05/06 to 26/05/06. The acting New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 13 manager reported that the service user had accessed the community during this period however the record had not been updated. Staff spoken with demonstrated a commitment to exploring opportunities that would enhance the quality of life for the service user. On the day of the visit, staff were observed to support the service user to access the community for an activity and lunch out, using the home’s minibus. A holiday had been planned with the people living in the home for July 2006. At the time of the visit the home was awaiting approval from senior management in order to proceed with the booking arrangements. Learning logs were used to record service users’ opportunities for personal development such as developing their independent living skills. Logs recorded information on the activity undertaken, (for example housekeeping tasks such as cleaning, washing and making beds), the aims of the activity and details of who provided the support. Staff spoken with demonstrated a good awareness of the rights of the people living in the home and how to treat service users with respect, privacy and dignity in their day-to-day practice. Essential Lifestyle Plans identified who was important in each service user’s life and the support required to maintain fulfilling relationships. One resident was in regular contact with a relative who also acted as an advocate for the people living in the home. An advocate spoken with reported that the service users were “Very well cared for” and that “I can go to the home any time I want.” The visitors’ book showed that home had visitors at different times. The acting manager reported that the home had a food budget of £100.00 pounds per week. A menu plan was in place, which showed that a variety of healthy food was offered to service users, however deserts had not been recorded. Staff shopped for food on a weekly basis at a local supermarket. Support staff spoken with advised that although service users were unable to vocally express their dietary preferences / choices, they were able to indicate a dislike of any food / meal by refusing to eat. As noted at the previous inspection, this information had been documented in Essential Lifestyle Plans and staff continued to monitor food intake. At the time of the visit the food stocks in the home were low. The acting manager reported that a shopping trip was planned. New Hutte Lane, 9 DS0000021495.V295736.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 and 20 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. Service users received personal and health care support, subject to individual needs. Some medication records were incomplete and did not provide an audit trail. This has the potential to place the welfare of residents at risk. EVIDENCE: Essential lifestyle and private plans provided information on the personal care and support needs of the people living in the home. Staff spoken with demonstrated a good awareness of the needs of the service users and had a positive attitude to supporting the people living in the home. Staff were observed to be attentive and supportive to the individual needs of service users during the visit and the service users appeared relaxed and content in their home environment. Each service user was registered with a general practitioner and had a ‘Health Action Plan’, which detailed how the general health care needs of individual service users were to be met. Records detailed a variety of input from a range of health care specialists in addition to the usual routine checks. The manager had kept health Action Plans under regular review. A record of health related appointments was also maintained, to monitor visits to and from health care professionals and the outcomes. New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 15 The home had a medication policy and guidance on when to give medication that was “give as required”. Training records showed that staff responsible for the administration of medication had completed training and this was confirmed in discussion with staff. None of the service users self-administered medication. Medication was stored in a lockable cabinet in the staff bedroom. At the time of the visit some medication was not being stored safely as it was stored on top of the cabinet. The acting manager agreed to make arrangements to store the medication safely during the inspection. No controlled drugs were being stored in the home on the day of the visit. Medication Administration Records (MAR) were viewed for each service user. There was no audit trail for medication as the date and quantity of medication entering the home had not been recorded on MAR and records had not always been completed to confirm the administration of medication. New Hutte Lane, 9 DS0000021495.V295736.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): Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. There had been no complaints since the last inspection and information about how to complain was discreetly displayed within the home. Safeguards were in place to protect service users from abuse. EVIDENCE: The home had a complaints procedure, which had been developed by the Registered Provider (The Brothers of Charity). A full version was available in the office/ staff bedroom and a laminated version was displayed on the wall of the office. Complaints were dealt with at the main site of the organisation in Huyton. The complaints record book for the home was viewed. This showed that no complaints had been received since the last inspection. Likewise, the Commission for Social Care Inspection had received no complaints about the service. An advocate for the people living in the home was contacted and confirmed that he had no current concerns or complaints. The advocate was able to confirm that the organisation was prepared to listen to any concerns and responded to complaints quickly. Policies and procedures were in place to ensure an appropriate response to suspicion or evidence of abuse. Staff interviewed demonstrated a good awareness of the different types of abuse, reporting procedures and their duty to protect vulnerable adults. Discussion with staff and training records viewed confirmed that staff had completed training in the Protection of Vulnerable Adults and received a staff handbook with guidelines on abuse awareness. New Hutte Lane, 9 DS0000021495.V295736.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, 25 and 30 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. All communal areas were maintained to a good standard however some bedrooms were in need of attention, to improve the environment for the people living in the home. EVIDENCE: The acting manager reported that the Registered Provider (The Brothers of Charity) was responsible for the maintenance of the property. A maintenance book was in place to record hazards / work requiring attention and records were available to confirm staff undertook quarterly health and safety inspections. All areas of the home including the bedrooms were viewed. Since the last inspection a new shower / wet room had been fitted into the property. Overall, areas viewed appeared to be maintained to a reasonable standard however a front bedroom required redecorating as the wallpaper was bubbling near the chimneybreast. Likewise, the other front bedroom had damaged wallpaper behind a chair and some bedroom furniture was showing signs of wear and tear. New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 18 The garden was well maintained and had been adapted for Service Users who have physical disabilities and visual impairments. Areas viewed appeared safe, clean and hygienic. Staff were responsible for cleaning and cooking in the home. Discussion with staff and examination of training records showed that the majority of staff had completed Infection Control and Food Hygiene training. Records showed that the home had facilities to dispose of clinical waste and polices and procedures were in place to control the risk of infection. Chemicals / cleaning products were safely stored and the Control of Substances Hazardous to Health (COSHH) guidelines were in place. New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to the service. The welfare of service users was protected through good recruitment practice. Service users were supported by staff that knew them well and had received training to meet their needs. EVIDENCE: The home employed 9 support staff. Examination of rotas, direct observation and discussion with the acting manager and staff confirmed that the team was stable and that two staff were on duty through the day. At night, the home had one waking night staff and an additional staff undertook sleep-in duties. Records showed that two staff had completed a National Vocational Qualification (NVQ) in care at level 2 or above (22.22 ). The acting manager reported that a further three staff had also completed a NVQ in care at level 2 or above and were awaiting their certificates. Once certificates have been received, this will bring the total to (55.5 ). Documentary evidence of training completed was not available however training plans and records showed that the Organisation (Brothers of Charity) provided staff with a good range of training opportunities to develop knowledge, skills and understanding. Staff spoken with confirmed they had completed a range of training and demonstrated a good awareness of equality and diversity issues, the principles of care and their roles and responsibilities. New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 20 The home did not have a recruitment and selection policy on the premises. Recruitment was coordinated from the Organisation’s head office and this was confirmed in discussion with staff. Only one new member of staff had commenced employment at the home since the last visit. The necessary pre-employment checks and records had been obtained. New Hutte Lane, 9 DS0000021495.V295736.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 and 42 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to the service. Further work was needed to develop and put into practice a quality assurance system, to demonstrate that the service is run in the best interests of the people living in the home. Not all the required certificates and safety checks were in place, to prove that the home is a safe place to live. EVIDENCE: At the time of the visit the home did not have a Registered Manager in post. The Commission for Social Care Inspection had received notification from the Registered Provider that the acting manager (Sheila Fitzpatrick) was in the process of applying to the Commission to register as the manager of the home. Discussion with the acting manager and examination of her training records confirmed that she had attained the National Vocational Qualification level 4 Registered Managers Award and had completed a range training that was relevant to the management and care of services for people with learning disabilities. The acting manager had previously managed a small care home for adults with learning disabilities. New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 22 The acting manager reported that since the last inspection, the Organisation (The Brothers of Charity) had developed a new quality assurance system that was at the consultation stage and that plans were in place to introduce the system in the near future. Monthly reports had been completed by the Organisation in accordance with Regulation 26 of the Care Home Regulations 2001. Examination of training records and discussion with staff confirmed that staff had access to regular Safe Working Practice training which included; Moving and Handling, Food Hygiene, Health and Safety, Infection Control and Fire Awareness Training. Fire records were viewed for the property. These showed that the smoke detectors were tested on a weekly basis, however there was no record of the emergency lights being tested. A fire risk assessment had been developed and this had been reviewed during February 2006. A record of fire drills was in place. Service certificates were available for the fire extinguishers, gas safety and portable appliances however there was no electrical wiring certificate to confirm the electrical supply to the property was safe as required at the last inspection. The acting manager reported that the home was fitted with thermostatic valves to regulate the temperature of the water however there were no records to confirm the temperature of the hot water outlets were checked. New Hutte Lane, 9 DS0000021495.V295736.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 4 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 2 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 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 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 2 X New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 24 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 YA39 Regulation Requirement Timescale for action 31/07/06 24 (1) (a) The manager must ensure that (b) (2) (3) quality assurance surveys are undertaken at New Hutte lane and familiarise himself with this standard and relevant regulations. 13 (2) Medication Administration Records must be signed to confirm the administration of medication. The date, quantity and initials of the person receiving medication into the care home must be recorded on Medication Administration Records. The home must obtain an electrical wiring certificate and forward a copy to the Commission for Social Care Inspection. 2. YA20 15/07/06 3. YA20 13 (2) 15/07/06 4. YA42 23 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 25 No. 1 2. 3. 4. Refer to Standard YA13 YA17 YA25 YA42 Good Practice Recommendations Records of all community-based activities should be up-todate and maintained for all service users. A record of deserts should be recorded on the menu. Action should be taken to repair the bedrooms in need of redecoration. The hot water temperature in the bathrooms should be periodically checked to confirm it is regulated to 43°C and records should be maintained. New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 New Hutte Lane, 9 DS0000021495.V295736.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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