Inspection on 08/10/07 for Newsome Road

This inspection was carried out on 8th 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Newsome Road 15/10/08

Newsome Road 14/02/07

Newsome Road 31/01/06

Newsome Road 23/08/05

Newsome Road 02/11/04

Newsome Road 27/04/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Newsome Road 35&37 Newsome Road Newsome Huddersfield West Yorkshire HD4 6NH Lead Inspector Alison McCabe Key Unannounced Inspection 8th October 2007 1.00pm Newsome Road DS0000026325.V352302.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 Newsome Road DS0000026325.V352302.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. Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Newsome Road Address 35&37 Newsome Road Newsome Huddersfield West Yorkshire HD4 6NH 01484 430509 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) macdonald@bridgewoodtrust.co.uk Bridgewood Trust Limited Mr George Eric Lockwood Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2007 Brief Description of the Service: 35/37 Newsome Road is a care home providing accommodation and personal care for up to five younger adults with learning disabilities. It is run by the Bridgewood Trust, a voluntary organisation specialising in the care of people with learning disabilities. Yorkshire Housing Association owns the premises. The home is located in a residential area close to the centre of Huddersfield. It consists of two adjoining houses of the same style as those in the area. The houses provide accommodation for two residents and staff sleeping-in room in one house and accommodation for three residents in the adjoining house. Accommodation is provided on two floors in both houses, and the first floor is accessed by a flight of stairs. No passenger or stair lift is available. The premises have enclosed, well maintained gardens to the rear. Fees at the home start at £403.30 to £494.19 per week. Items not covered by fees include toiletries, outings and holidays. Information about the home and the services provided are available from the home in the Service User Guide. Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit to this home was unannounced and conducted between the hours of 1 pm and 6.30 pm. As part of this inspection, information provided by the home’s manager in advance of this visit has been used. This included information about people living at Newsome Road, their relatives and professionals involved with them, so that surveys could be sent out asking their opinions about the service. Completed surveys were received from four people living at the home, one relative and one care manager. No staff surveys had been returned at the time of this report. At the time of the visit, the manager was on annual leave. The ex-manager, who is still employed by Bridgewood Trust at another of their homes, very kindly agreed to come in to assist with the inspection. The newly appointed area manager for the home was on her first day of induction and took part in the inspection process. During the visit, the inspector also had the opportunity to meet with a member of the care team and people living at the home. The inspector saw communal areas of the home and looked at records relating to staff, management and people living at Newsome Road. The inspector would like to thank all those involved for their hospitality and assistance during this visit. What the service does well: Before people move into the home, their needs are properly assessed. Good opportunities are offered to people to participate in a variety of activities in the community. Staff offer good support to people to enable them to maintain contact with their families and friends. People living at the home have good relationships with the staff and the staff know them well. Individuals are supported to have their health and personal care needs met. Good food is provided. The home has a clear complaints procedure and people know how to use this. Newsome Road is a clean and comfortable environment. Staff receive training relevant to the service they are providing. Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 6 Recruitment practice is good. All the required checks on staff are carried out before they work at the home. People benefit from living in a well run home with a stable staff team. There are good policies and procedures in place to protect individuals from harm or abuse. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Newsome Road DS0000026325.V352302.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 Newsome Road DS0000026325.V352302.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): 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. People’s needs are appropriately assessed before they move into the home. EVIDENCE: Records relating to four people were looked at and all contained evidence that pre-admission assessments had been conducted. Since the last inspection there have been no new admissions to the home. All those who completed a survey, as part of this inspection, indicated that they were given sufficient information about the home before they moved in to help them to decide if it was the right place for them. Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 9 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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Clear information about how to meet people’s personal care needs are recorded, however further development is necessary. The management and assessment of risks needs to be much clearer to safeguard people from potential harm. EVIDENCE: Care plans relating to four people were seen. All contained some good information about how individuals’ personal care needs should be met, however there is a lack of information about individuals’ social and emotional needs and how these should be met. Some areas of the care plan need further development as they are rather vague. New care planning documentation is to be introduced soon which should address these matters. Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 10 There is evidence of regular reviews taking place. Prior to the review, people are asked to complete a satisfaction questionnaire. It was noted that the previous registered manager had completed these with the individual. It is recommended that a more independent person be asked to support individuals with this, so that people feel free to express their opinions of the service, for example, family or advocate. Risk assessments are in place, however there is work to do to improve some of these as they do not clearly identify the risk or agreed actions to minimise risks. Risks identified during the inspection had not been clearly assessed and some of the recorded measures to reduce risks were vague and open to interpretation. In order to better protect people form potential harm, risk management at the home needs to improve. Although most people who completed a survey indicated that they are given choices about what they do, having spoken to people living at Newsome Road, it seems that this is not always the case. Again, it was found that the acting manager had filled in all completed surveys with individuals, and the same recommendation to access independent advocates or support is made. People living at the home explained that staff choose where they go on holiday and who they would share a room with and said they have little choice in this. Some individuals also said that staff choose what meals people have on a daily basis. There is evidence that people are supported to make some choices, for example, an individual who has chosen not to attend a variety of evening activities now stays in the home on his own. It was noted, when looking at financial records, that all the people living at the home had contributed to a staff leaving present. There was no record to evidence that this had been discussed or agreed with individuals, however one person did confirm that he was asked although he had not been informed how much would be taken from his account. There needs to be more emphasis on a person centred approach recognising the rights and responsibilities of the adults living at the home. Information provided by the home’s manager prior to the inspection describes changes to the way in which residents’ meetings are conducted. These used to be a formal meeting, however the new manager reports that this was not always the best way of encouraging everybody to contribute. These formal meetings have, therefore, been replaced with a more informal approach, whereby discussions take place over the evening meal. The manager then records the discussions and any decisions made. It is positive that different approaches are tried in an attempt to include everybody living at the home in these meetings, although arrangements should be made to ensure everybody has access to the minutes. Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 11 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): 12,13,15,16,17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People lead active and fulfilling lives where they are supported to keep in touch with family and friends and their rights and responsibilities are usually recognised. The meals are good, however choices regarding meals are not promoted. EVIDENCE: People lead active lives and participate in a range of educational and leisure activities. Those individuals spoken to reported enjoying going to college or day services. On the day of inspection, some people were going swimming in the evening. Comments were received, from both a relative and a care manager, suggesting that a more individual approach might be supported to enable people to have more choice about whom they socialise with or go on Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 12 holiday with. People spoken to during the inspection said that they had little choice about whom they went on holiday with. There was evidence in the records, and through discussion with the exmanager, people living at the home and staff, that people are supported to maintain contact with family and friends. A relative who completed a survey as part of the inspection, indicated that the home was good at keeping in touch and keeping them informed of any important matters relating to their relative. Individuals’ rights and responsibilities are respected and recognised most of the time. People are usually supported to lead independent lives with the appropriate support. It was noted that people had keys to their bedrooms and staff did not enter without permission. The ex-manager explained that people are given the choice of whether to join in with activities, and an individual living at the home confirmed this. Everybody spoken to said that they enjoy the meals that are provided. On the day of inspection, the meal was corned beef hash and vegetables. People living at the home all stated that staff choose what the meals will be and do all the cooking. The manager has since explained that people are encouraged to help with drawing up a menu for the week and that people’s initials are put on the menu to indicate whose choice it has been. All the people living at Newsome Road eat their meals together in the evenings. The member of staff on duty cooks the meal in one house, and the individuals that live next door come round for their meal each day. The ex-manager explained that this arrangement has been made as all the individuals need support with cooking and there are not enough staff to do this; staff usually work alone. It is recommended that the manager explores how people might be supported to participate in the preparation of meals so that they can eat in their own home, and not have to rely on going to their neighbours each day. Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 13 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. People’s personal and health care needs are generally met, although identified needs or potential changes in health are not always followed up appropriately. Medicine management is generally good. EVIDENCE: Clear information about what support people need with personal care was seen in the records. The home continues to use a numbering system where each element of the personal support plan has a number and staff record which element has been delivered by noting the number in the daily records. It was discussed at the last inspection that this did not demonstrate satisfactorily how people’s needs had been met. It was found at this inspection that, in addition to this system, a daily observation record is kept giving a summary of how people’s needs have been met. This gives a reasonable amount of detail to show whether or not individuals’ needs have been met as planned. Feedback from a relative suggests that there are not always sufficient numbers of staff Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 14 to give the necessary support with personal care needs, although there was no evidence in the records or from observation on the day of inspection that there are difficulties in this area. However, this has been discussed with the manager of the home who has agreed to ensure that this is monitored. There was evidence in the records that, in general, people’s health care needs are met appropriately. Support is given to people to attend healthcare appointments and a variety of healthcare professionals are involved in the care of the people living at the home. It was noted in one individual’s records that there had been an apparent weight loss of two stones in eight weeks. The area manager has since spoken with the inspector to clarify that the member of staff who had made the entry has reported that the scales were faulty at the time, and this was in fact incorrect. It is important that staff do not simply record incorrect information but take the appropriate action to replace faulty equipment or to explore possible reasons for such a significant weight loss. It was also noted in an individual’s care plan that they needed to lose weight, however there was no agreed plan about how this might be achieved or monitored. Medication was checked and found to tally with the records kept. Clearer instructions and records need to be kept in relation to the use of ‘as required’ medication. For example, an individual with a prescription for a daily antihistamine had not been given this medication daily, as it is not required all year round, however there was no guidance for staff about under what circumstances this should be administered. This was discussed with the area manager at the time of the visit. An individual at the home is supported to self medicate and this is positive. Although a risk assessment is in place, this does not clearly describe the potential risks and steps taken to minimise these risks. The area manager explained that this would be addressed as part of the introduction of the revised care planning and risk assessment system. Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 15 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 living at this home are protected by clear complaints and safeguarding procedures. EVIDENCE: A clear complaints procedure is in place that is also available in symbol format. Information provided by the home’s manager prior to the inspection states that there have been no complaints received at the home in the last twelve months. Most people living at the home, and a relative, indicated on the surveys that they are aware of the complaints procedure, and that staff listen and act upon what they say, with the exception of one person who commented, “I find it annoying that sometimes my comments are ignored”. This should be taken up by the manager of the home to ensure that individuals are confident that their comments will not be ignored. Since the last inspection, revised safeguarding policies and procedures have been introduced throughout the Bridgewood Trust. There was evidence in staff’s support and supervision records that this has been discussed with them, and a member of staff confirmed this. There is clear guidance for staff about what to do in the event of suspected or actual abuse, and this is in line with Kirklees multi-agency guidelines. No referrals of a safeguarding nature have been made in the last twelve months according to the information provided by the manager prior to the inspection. Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 16 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. People live in a clean and comfortable home. EVIDENCE: Although Newsome Road is registered as one service, it is two houses next door to each other. One house provides accommodation for two individuals and a staff sleep-in room, and the adjoining house provides accommodation for three individuals. Both houses have lounge, kitchen/diner and bathroom facilitates and they share a well maintained garden. A tour of the communal areas of both houses was conducted. Both houses were clean, tidy and well maintained. All those who completed a survey said that the house is always clean and fresh. It was noted in one bathroom that Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 17 the hot water temperature was excessively hot although the home manager has since informed the CSCI that this has been adjusted. Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 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. People are supported by a stable and competent staff team who have had the necessary checks done before they work at the home, however there are not always sufficient numbers of staff on duty to meet the needs of the people living at the home. EVIDENCE: Information received prior to the inspection states that, of two care staff, one has achieved National Vocational Qualification (NVQ) in care at level two or above and the second staff member is currently working towards this. The ex-manager who works at another of Bridgewood Trust homes assisted with this inspection, and a member of care staff was also present for some of the time. People living at the home appeared to be comfortable with the staff and said that they had good relationships with them. Some examples of good care practice were observed where staff presented as approachable and Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 19 interested in the people living at the home. There were, however, some examples of care practice that came across as somewhat parental and controlling rather than empowering people as adults in their own home. Some of the entries in individuals’ care plans or daily records did not demonstrate positive attitudes and these were pointed out to the area manager at the time of the inspection. It is clear, however, that staff know the people who live at Newsome Road very well and have an understanding of their needs and wishes. The home’s manager has since been in touch with the inspector and has expressed his commitment to empowering people at the home to have more choice and control over their lives which is positive. The home benefits from a stable staff team. The two care staff have worked at the home for several years and this provides consistency for the people living there. There has been a change of manager since the last inspection and people said they had a good relationship with him. There was evidence in the records that regular staff meetings take place and minutes of these meetings are kept. It was required at the last inspection that a review of staffing levels be conducted to ensure that there are always sufficient numbers of staff to meet the needs of the people living at Newsome Road. Staff work alone most of the time with a manager on call. Due to the current arrangement, whereby people living in number 35 have to have their meals at number 37 because there are not enough staff to support them to make their meals in their own home, this requirement has been repeated. Additionally, comments from a relative also suggest that there are not always enough staff to support people with their personal care needs. Consideration must be given to increasing staffing levels at key times of the day when the people using this service need more support. It was commented upon, at the last inspection, that there are occasions where individuals are alone in the home if staff are supporting those people that want to go out. A requirement that individual risk assessments be carried out for those people who stay at home has been addressed in part. Although risk assessments had been completed, they did not clearly describe the identified risks or how to minimise these risks, and therefore the requirement has been repeated. Staff training records show that a range of relevant training has been provided since the last inspection. Staff have recently received training regarding safeguarding vulnerable adults and fire safety training. A staff member confirmed that she had also attended training regarding Autistic Spectrum Disorder, which is relevant to the people who use this service. Since the last inspection, a new training manager has been recruited and a staff training and development plan is in place. Staff recruitment records show that the required checks have been completed. The ex-manager explained that potential new staff go through two interviews; Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 20 one formal interview with a panel and a second informal interview where they visit the home and meet people living there. People using the service are then invited to give their feedback about candidates and ask them questions during the visit. This is good practice. Newsome Road DS0000026325.V352302.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. 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. Newsome Road is a generally well run home, where people’s views are taken into account and the health and safety of people is protected in most areas. EVIDENCE: Since the last inspection a new manager, Mr Peter Foy, has taken over at Newsome Road and has recently been registered by the CSCI. Unfortunately, Mr Foy was on annual leave at the time of the inspection and the ex-manager kindly agreed to assist in his absence. Mr Foy has a National Vocational Qualification (NVQ) in care at level three and explained that he has just commenced the Registered Managers’ Award and NVQ level four in care. Mr Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 22 Foy commenced at Newsome Road in March 2007, and staff and some people living at the home reported that they were still getting to know him. Mr Foy has had previous experience as a senior carer working within older people’s services. The Bridgewood Trust uses a formal quality assurance system (ISO) and, in addition to this, people’s views of the service are ascertained through residents’ meetings and satisfaction questionnaires. As stated previously, it was noted that all the satisfaction questionnaires had been completed with staff support and it is recommended that, if this is necessary, someone who is independent of the home provides this support. Information provided prior to the inspection states that maintenance of equipment and the premises has been carried out at the required intervals, with the exception of portable appliance testing which is overdue and needs to be completed. Whilst touring the premises, a check of hot water temperatures was made. The hot water temperature in the first floor bathroom in 37 was found to be excessively high, measuring 65°C; the recommended temperature is 43°C. The water was too hot to put your hands under, in order to wash them. It was noted that hot water temperatures had been recorded as excessively high over a period of years, with an engineer recommending that temperature regulators be fitted. It is recommended that staff be made aware of the recommended temperatures and know what action to take if temperatures are recorded as too high or too low. Since the inspection, the manager has informed the CSCI that remedial action has been taken to ensure the water temperature is at a safe level. As discussed previously in this report, in order to protect the health and safety of people living at the home, further development of risk assessments is necessary and risk management in some areas needs to improve. A requirement has been made in respect of this. Newsome Road DS0000026325.V352302.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 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 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 YA33 Regulation 13. (4)(c) Requirement Risk assessments must clearly identify the nature of the identified risks and give clear instructions about what steps should be taken to minimise the risks. This should include selfadministration of medication, being alone in the home, and the management of challenging behaviour along with other identified risks. Timescale of 19/03/07 unmet A review of staffing levels must be undertaken to ensure that there are sufficient staff to care for the health and welfare of people at the home at all times, taking into account the current needs of the people receiving a service. Timescale for action 30/11/07 2. YA33 18-(1)(a) 30/11/07 Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 25 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 YA6 Good Practice Recommendations Individual care plans should cover all aspects of personal and social support and healthcare needs as set out in standard 2 of the National Minimum Standards, and should be developed using a person centred approach. Where support is required to complete satisfaction surveys, it is recommended that this be provided by a person independent of the home, ie not the home’s manager or care staff working at the home. Care should be taken to ensure that people using the service are supported to make choices about their lives with the appropriate support. People should be given the opportunity to participate in meal preparation with the appropriate support. Individuals should not be expected to have meals in their neighbours’ home due to insufficient numbers of staff on duty. Where health care needs have been identified, or changes in people’s health have occurred, good systems for monitoring and planning appropriate care need to be put into place. Where medication is prescribed on an ‘as required’ basis, clear guidance needs to be in place to advise staff when this should be given. 2 YA7 YA39 3 4 YA7 YA17 5 YA19 6 YA20 Newsome Road DS0000026325.V352302.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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