Inspection on 29/08/06 for Nottingham Neurodisability Services Aspley

This inspection was carried out on 29th August 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

Nottingham Neurodisability... 07/07/08

Nottingham Neurodisability... 19/12/07

Nottingham Neurodisability... 28/08/07

Nottingham Neurodisability... 06/12/05

Nottingham Neurodisability... 23/05/05

Nottingham Neurodisability... 13/07/04

Nottingham Neurodisability... 10/06/04

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

CARE HOME ADULTS 18-65 Nottingham Neurodisability Services Aspley Robins Wood Road Aspley Nottingham NG8 3LD Lead Inspector Steve Keeling Key Unannounced Inspection 29th August 2006 9:00 Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.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 Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.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. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nottingham Neurodisability Services Aspley Address Robins Wood Road Aspley Nottingham NG8 3LD 0115 942 5153 0115 942 5154 aspley@fshc.co.uk 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) Four Seasons Homes (Ilkeston) Ltd Post Vacant Care Home 32 Category(ies) of Physical disability (32) registration, with number of places Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2005 Brief Description of the Service: Aspley Neurodisability Unit is a purpose built unit situated in the inner city area of Nottingham in Aspley. The home is within access to local shops, library, health centre, churches and a pub. The communal lounges of which there are two and a designated dining area are situated on the first floor. Resident’s rooms are both on the ground floor and the first floor. All personal rooms are of single occupancy and fitted with an en-suite facility. A passenger lift facilitates access to the first floor. Four Seasons Healthcare Limited was registered in February 2004 with the Commission for Social Care Inspection as the registered providers. The fees currently charged at the home are £550 per week. Additional cost for hairdressing, newspapers, toiletries, holidays and podiatry intervention are charged at current retails prices. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over a 9 hour period and involved one inspector. The main method of inspection was case tracking, this is a method of selecting residents within the home and discussing with them their expectations and experiences within the home together with the care practices utilised within the home environment. The case tracking method also examines the records of the residents to ascertain if the residents identified needs are being addressed appropriately within the care home setting and that their safety and well being is being maintained. On this occasion two residents notes were case tracked. Also as part of the case tracking process a two staff members within the home was informally interviewed to further evidence the quality of care afforded to the residents. A range if information was used to determine the outcome of this inspection and the report, these included the previous judgments and findings, the information received from residents in response to the Commission for Social Care Inspection questionnaires and the pre-inspection information provided by the registered provider in July 2006. The report indicates minimal comments from the residents, primarily due to the nature of the illness of those accommodated although the inspector utilised direct observation to establish the residents experiences within the home. What the service does well: A resident stated that she felt safe within the homes environment and felt her privacy was respected and their dignity was upheld. A resident’s stated that she is encouraged to interact and maintain appropriate relationships within family and friends within the home. The inspector witnessed several interactions between residents and staff on the day of the inspection; the interactions were performed in a caring and sensitive manner. A resident stated that she felt confident that any concerns and complaints will be listened to and acted upon appropriately by the acting manager at the home. An examination of staff training documentation evidenced that staff at the home receive appropriate training in relation to adult abuse awareness, thus ensuring the residents are safe within the homes environment. A range of health and safety documentation provided by the acting manager prior to the inspection demonstrated that the resident’s safety is protected and promoted at the home and a resident stated that the home is comfortable, safe and well maintained. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 6 An appropriate number and skill mix of staff are employed at the home to meets the resident’s identified needs and staff at the home receive appropriate mandatory training to ensure they are competent in performing their duties within the home. 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. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.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 Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome group is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The pre-admittance assessments examined on the day of the inspection did not ensure that the resident’s holistic needs were identified and that the resident’s holistic needs were being met. EVIDENCE: The home utilises the Activities of Daily Living tool (ADL) in an attempt to highlight the resident’s holistic needs. The assessment documentation within the two case tracked notes identified the physical and psychological needs of the resident but the resident’s individual aspirations and goals were not addressed. The registered person is required to ensure that all potential residents undergo an effective pre-admittance assessment and that the assessment process identifies individual goals and aspirations so that all residents within the home are encouraged to achieved their maximum potential. On the day of the inspection the acting manager confirmed that this element within the assessment process continues to require further development. The acting manager stated that the assessment process would be re-evaluated by 30th November 2006 in an attempt to establish all the resident’s aspirations and goals within the home. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome group is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The care planning procedures within the home were ineffective and resident’s safety could be compromised. Residents are encourage to make in dependent decisions about their own life The Residents ability to take risks as part of an independent lifestyle is compromised due to ineffective evaluation procedures at the home. EVIDENCE: Care plans were formulated which addressed the identified needs of the residents on admission, but as mentioned earlier in the report the resident’s aspirations and gaols were not addressed effectively as no care plans were evident in relation to this element of care. The care plans within both case tracked notes had not been re-evaluated effectively to address the changing needs of the residents. Care plans relating to pressure ulcer prevention, the management of seizures, communication, environmental safety, nutrition, weight monitoring, mobility, Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 10 hygiene and dressing were all found to be ineffectively evaluated which could compromise the safety of residents within the home. As far as practically possible the registered person is required to ensure that residents care plans are reviewed with the resident (involving significant professionals, and family, friends, and advocates as agreed with the resident) at the request of the resident or a least every six months and updated to reflect changing needs; and agreed changes are recorded and addressed. The aforementioned practice could not be evidenced in the case tracked notes. One case tacked resident had a history of methicillin-resistant staphylococcus aurues (MRSA) infections. An examination of the resident’s notes did not evidence any documentation relating to the management of the residents MRSA, which could compromise the safety of the residents at the home. The registered person is required to initiate appropriate policies and procedures and formulate effective care plans to ensure that residents with MRSA infections are identified and staff at the home are aware of the actions are to be taken to protect fellow residents and staff from potential infection. The care planning documentation examined on the day of the inspection was somewhat disorganised and bulky and does not necessitate ease of access to information relating to the care needs of the residents, which could place the residents at risk. To ensure the safety of all residents within the home the registered person is required to re-evaluate all the residents care plans to ensure that the care plans are up to date and pertinent to the holistic needs of the residents. To ensure that residents are encourage to make in dependent decisions about their own life the acting manager stated that resident meetings are performed on a regular basis so as to provide an open forum for discussions appertaining to care provision, social activities and dietary preferences within the home. A case tracked resident and the social activities coordinator also confirmed that the meetings take place. The case tracked resident, who currently “chairs” the residents meeting stated that she felt fully informed of any developments within the home and went on to say that she believed residents views and wishes are valued at the home. The inspector witnessed several interactions between residents and staff within the communal lounge area on the day of the inspection. The interactions were respectful, empowering and facilitated the resident’s autonomous choice as staff offered guidance rather than instructions for the residents. As mentioned earlier in the report the resident’s ability to maintain an independent lifestyle is compromised at the home, as the evaluation of the resident’s aspirations and goals is currently ineffective. The acting manager stated that it is difficult to establish the needs of some residents at the home due to some resident’s compromised communication abilities. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 11 In addressing the aforementioned shortfall the acting manager stated that, in conjunction with Social Services all the residents at the home are to undergo an assessment and re-evaluation process. The multidisciplinary assessment process will identify appropriate actions and interventions to ensure that the residents achieve their optimum physical and psychological potential within the home and the acting manager is awaiting a date from Social Services as to when the assessment will take place. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.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, 17. Quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. Resident’s now benefit from the provision of a varied social activities programme. Resident’s are encouraged to interact within the local community. Resident’s can maintain appropriate relationships within family and friends. Resident’s rights and responsibilities are respected at the home Resident’s are offered a healthy diet and enjoy their meals within a pleasing environment. EVIDENCE: Through discussions with the acting manager, a resident and staff members it was established that residents are encouraged to participate in a varied social activities programme within the home and within the local community. A case tracked resident stated that the activities within the home have improved significantly since the employment of an activities coordinator. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 13 The resident confirmed that activities include Arts and Crafts, newspaper readings, to ensure residents are informed in relation to current events, indoor bowls and crossword sessions. A large wide screen television was also evident in the residents lounge together with a DVD player so residents can enjoy films and television programmes. A resident and a staff member also confirmed that a minibus had been made available for residents to access day trips to local areas of interest such as parks and the Sea World Centre in Birmingham if they choose to. The acting manager and staff at the home stated that the home operates an open door policy in relation to visitations so as to facilitate and maintain appropriate relationships within family and friends. At the time of the inspection no relatives or friends were visiting the home although a case tracked resident confirmed the open access policy at the home and she confirmed that friends could visit whenever they wish. A case tracked resident confirmed that residents are consulted via residents meeting to establish the preferred choice of meals and snacks at the home. A case tracked resident stated that the food at the home has improved significantly since the employment of a new chef and stated that “it just gets better and better”. On the day of the inspection, the resident’s dining room was inspected. The dining room was maintained to a high standard and provided a dining area that was both safe and aesthetically pleasing. All the dining tables had tablecloths together with condiments and potted flowers so as to provide a pleasant dining experience for residents at the home. A weekly menu was displayed in prominent position within the home so as to promote the residents choice and the daily menus had a least two meal options so as to promote choice. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome group is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The inspector could not fully ascertain if the residents receive personal support in a way they prefer and require due to ineffective documentation. The inspector could not determine that the resident’s physical and emotional needs are met at the home, once again due to ineffective documentation. Policies and procedures in relation to the management of medicines were not being followed fully, which could compromise the safety of residents at the home. EVIDENCE: It was difficult to determine if the resident’ physical needs and preference are fully met at the home. As mentioned earlier in the report the assessment and care planning documentation is ineffective in relation to determining the preferences of the residents and requires significant improvements to meets the standards identified within the National Minimum Standards Act (2000). A case tracked resident stated that they she was satisfied with the level of personal support and care she received at the home and stated that the staff at the home are always respectful and respond appropriately to her requests in relation to personal care and support. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 15 The residents pre-inspection questionnaires asked residents “do the carers listen and act on what you say”, only 42 of the responses received by the Commission for Social Care Inspection stated “always” with 42 stating “usually” and 14 stating “sometimes”. The registered person is required to initiate a system, which allows for the clear identification of the resident’s preferences in relation to personal care so as to fully inform staff and respect the resident’s wishes in relation to personal care provision. As part of the case tracking process the case tracked residents Medication Administration Records (MAR) were examined. It was evident that one case tracked resident had gaps within the MAR charts with no explanation as to why the resident had not received the medication. MAR charts should not have gaps present, if medication cannot be administered an explanation must be documented and appropriate “key” must be used. The registered person is required to evidence what actions will be taken to ensure staff adhere to this requirement so as to ensure the safety of residents at the home by 30th November 2006. The temperature within the medication fridge had been monitored but the temperature within the medication fridge was outside acceptable limits as the temperature was recorded at –2 degrees centigrade. To ensure that an optimum environment is maintained to prevent medication degradation the temperature within the medication fridge should be within a range between 2 degrees centigrade and 8 degrees centigrade. The registered person is required to ensure that medication which requires refrigeration are stored effectively to ensure medication degradation is inhibited by 30th November 2006. At the time of the inspection no resident’s were responsible for the selfadministration of medicines. The acting manager stated that should a resident wish to be independent in the administration of medicines the manager would perform a risk assessment, if the resident was deemed as being safe, the resident would be supported to be independent in relation to the selfadministration of medication. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents feel confident that concerns and complaints will be listened to and acted upon at the home. Residents are protected from abuse, neglect and self-harm. EVIDENCE: The complaints procedure is given to residents or their representatives on admission and the complaints procedure is also on display in the foyer of the home. 100 of the responses received by the Commission for Social Care Inspection surveys to the residents stated that residents know who to speak to if they are not happy. A case tracked resident stated that she felt safe within the homes environment and felt confident in discussing any concerns with the acting manager if she was unhappy with any aspects of care. An examination of the staff training records evidenced that training in relation to the protection of the vulnerable adult had taken place on 11th April 2006 and repeated on 2nd May 2006. Staff spoken with on the day of the inspection confirmed the training opportunities in relation to the protection of the vulnerable adult takes place at the home. The interviewed staff were aware of issues relating to the protection of the vulnerable adult and were able to identify appropriate actions which would be required from them if the suspected abuse was occurring in the home. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 17 Staff members spoken with stated that they would refer to the companies policies and procedures in relation to the protection of the vulnerable adult, document any complaints and concerns effectively and liaise with the acting manager. The staff members also stated that if they were not satisfied with the management of complaints they would contact outside agencies such as Social Services, the Commission for Social Care Inspection or the Police. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. Quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides a comfortable and safe environment which is well maintained and homely. Residents benefit from a home which is clean and hygienic. EVIDENCE: 85 of the responses received by the Commission for Social Care Inspection surveys to the residents said that the home is always clean and fresh. A case tracked residents stated they she was satisfied with her bedroom and the overall cleanliness of the home. The case tracked residents bedroom were seen on the day of the inspection and were found to be well-personalised safe and clean. Residents have audio and visual equipment in their rooms together with books, posters and family pictures. The inspector performed a partial inspection of the homes environment. The home had a high standard of cleanliness and all areas smelt fresh. Communal areas, which included the resident’s lounge and dining room, were aesthetically pleasing, clutter free and safe. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.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, 35. Quality in this outcome group is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. An appropriate number and skill mix of staff are employed at the home to meets the residents needs. Shortfalls were identified in relation to the recruitment process utilised at the home which could place residents at risk. Staff receive appropriate training and are competent in meeting the needs of the residents at the home. EVIDENCE: Staff employed at the home is sufficient to meet the needs of the residents and an appropriate skill mix was evidenced. An examination of the staff rota, on the morning of the inspection evidenced that six carers, and two qualified nurses were on duty. Throughout the afternoon period, five carers and two qualified member of staff were on duty and three carers and one qualified nurse covered the night period. Two staff files were examined on the day of the inspection. It was evident that policies and procedures in relation to the recruitment of staff had not been followed appropriately, which could place the residents at risk. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 20 The first staff file only had one written satisfactory reference and the second staff file did not evidence any written references. Further examination of the second staff file evidenced that a member of staff had commenced employment prior to the acquisition of the required Criminal Records Bureau checks (CRB). The ensure the safety of residents at the home, an immediate requirement was made to address this deficit so as to ensure that all new staff are confirmed in post only following completion of a satisfactory police checks together with two written references prior to staff employment at the home. The acting manager stated that all qualified nurses and care staff employed at the home undergo mandatory training to ensure that residents are safe within the home. An examination of the staff training documentation and a discussion with two staff members confirmed that the mandatory training opportunities are appropriate in ensuring the safety of residents within the home. A case tracked resident stated that the provision of care has greatly improved since the acting manager commenced employment at the home and stated that staff are competent and confident in performing their care duties at the home. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.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, 42. Quality in this outcome group is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The resident’s rights to live in a well run home is compromised due to shortfalls relating to the management of documentation within the home. Residents have the opportunity to provide input into the development of the home. A range of health and safety documentation has been provided by the acting manager at the home, which demonstrated that the resident’s safety is protected and promoted EVIDENCE: Discussions with the case tracked residents and information gleaned from the resident’s questionnaire indicate that the residents believe that the care provision within the home has improved since the employment of the acting manager. Comments taken from the residents questionnaire include “I have nothing to complain about”, “I feel that we have got one of the best managers we have Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 22 ever had” and “I think it’s a good home, all the staff are good, the managers good, the food is good and the activities are good”. Comments made by staff on the day of the inspection were all positive in relation to the acting managers abilities. A staff member stated that staff morale has improved significantly since the acting manager commenced employment and that the acting manager is always approachable and supportive. As mentioned earlier in the report, the acting manager in meeting the standards identified within the National Minimum Standards Act (2000) will be required to improve the evaluation and care planning processes at the home. The Commission for Social Care Inspection will consider taking regulatory action if compliance is not achieved following 30th November 2006. As mentioned earlier in the report a resident at the home confirmed that an effective consultation has been established at the home in the form of residents and relative meetings, which are performed on a monthly basis. The further aid the communication processes within the home the acting manager stated that she intends to initiate a questionnaire, which will be utilised by residents and the resident’s family and friends to identify any concerns in relation to the care provision at the home plus any suggestions in relation to the development of the home. In determining that the residents are safe within the homes environment a range of Health and Safety records were provided by the acting manager within the pre-inspection questionnaire, relating to Fire Safety training, fire equipment checks, emergency lighting checks, hoist and adaptation checks, Gas Safety Certificate, and all were found to be satisfactory. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.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 2 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 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 x 34 1 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 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 2 2 2 x 2 x 3 x x 3 x Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14 Timescale for action The registered person will ensure 30/11/06 that all potential residents undergo an effective preadmittance assessment and that the assessment process identifies individual goals and aspirations so that all the residents needs can be met. Outstanding requirement from 30/09/05 The registered person will ensure 30/11/06 that residents care plans are reviewed to ensure the resident’s needs are met. Outstanding requirement from 30/09/05 The registered person will ensure 30/11/06 that the management of medicines within the home is effective in ensuring the safety of residents. The registered person will ensure 29/08/06 that all new staff are confirmed in post only following completion of satisfactory police checks, and two written references are obtained before making an appointment. Requirement 2 YA6 15 3 YA20 13 4 YA34 19 Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.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 2 3 Refer to Standard YA9 YA37 YA18 YA19 Good Practice Recommendations The registered person should ensure that residents are encouraged to take risks as part of an independent lifestyle. The registered person should ensure that the management of all documentation is effective in ensuring the safety of residents at the home. The registered person should ensure that a system, which allows for the clear identification of the resident’s preferences in relation to personal care so as to fully inform staff and respect the resident’s wishes in relation to personal care provision. Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Nottingham Neurodisability Services Aspley DS0000059536.V306708.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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