Inspection on 08/06/06 for PIA 132 Manor Court Road

This inspection was carried out on 8th June 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

PIA 132 Manor Court Road 05/06/07

PIA 132 Manor Court Road 18/11/05

PIA 132 Manor Court Road 09/06/05

PIA 132 Manor Court Road 18/10/04

PIA 132 Manor Court Road 27/05/04

PIA 132 Manor Court Road 03/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Pia - Manor Court Road, 132/4 132 Manor Court Road Nuneaton Warwickshire CV11 5HQ Lead Inspector Kevin Ward Key Unannounced Inspection 8th June 2006 07:50 Pia - Manor Court Road, 132/4 DS0000004227.V298048.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 Pia - Manor Court Road, 132/4 DS0000004227.V298048.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. Pia - Manor Court Road, 132/4 DS0000004227.V298048.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pia - Manor Court Road, 132/4 Address 132 Manor Court Road Nuneaton Warwickshire CV11 5HQ 02476 383986 02476 640146 jmorrissey@people-in-action.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) People in Action Mrs Julie Ann Morrissey Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Pia - Manor Court Road, 132/4 DS0000004227.V298048.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 2005 Brief Description of the Service: 132/134 Manor Court Road is a registered care home for eight people with learning disabilities and has been separated into two separately staffed homes that occupy the top and ground floors of two semi-detached houses. Effectively these are two group living homes. People in Action provide 24 hr personal care and support. 132 Manor Court Road is situated on the ground floor of the house and can accommodate four people with physical and learning disabilities. Each service user has their own bedroom with shared facilities of a kitchen, bathroom with W. C., separate WC and large lounge/dining room. There is a separate laundry area. 134 Manor Court Road can accommodate four people with learning disabilities and is situated on the first-floor level of the house. Each service user has their own bedroom with shared facilities of a kitchen/dining area, laundry, and bathroom with WC and lounge. There is a shared garden to the rear of the house. The property is situated close to Nuneaton town centre. Rail and public transport links are nearby. There is limited off-road parking. Individual placement fees (at 8/6/06) range between 363.83 and 1104.43 per week. Service users are required to pay for personal items, such as hairdressing, toiletries, holidays, recreation, clothing and transport. Pia - Manor Court Road, 132/4 DS0000004227.V298048.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection focused on assessing the main key Standards and on reviewing progress to meet the requirements that were made at the last inspection. As part of the inspection process the inspector reviewed information about the home that is held on file at the Commission, such as notifications of accidents and incidents. The manager completed more information about the home. The inspection involved meeting with all the service users at the home. Due to service users communication needs it was only possible to receive verbal comments from one person living at the home. Questionnaires were sent to service users prior to the inspector’s visit, which were completed and returned with support from staff at the home. The inspection also involved talking with all the staff and team leaders who were on duty. A number of records, such as care plans, staff files and fire safety records were also sampled for information as part of this inspection. What the service does well: The staff at the home are attentive to service users needs and address them respectfully. Service users looked comfortable and at ease in approaching staff for assistance and staff responded with friendliness and care. A service user commented that he receives regular support from staff to attend health appointments. Information contained in service users health records confirmed that service users are supported to gain access to proper health advice and support, e.g. well persons checks and support to attend consultant appointments. Encouragement is given to service users to retain a degree of independence and control over their lives, e.g. they have been provided with keys to enable them to let themselves into the home and to lock away their possessions and are supported to shop for personal items and groceries. The home makes use of the dietician to advise and support service users concerning their dietary needs and to check the menus are balanced and appropriate and service users take part in shopping for groceries. Relatives are encouraged to visit service users at the home and staff have been provided with training in sexuality and personal relationships. This training is important so that staff respond appropriately and provide the correct advice and support for relationships. Pia - Manor Court Road, 132/4 DS0000004227.V298048.R01.S.doc Version 5.2 Page 6 Staff are provided with an extensive range of training courses so that they are properly equipped to work with service users in a safe and appropriate manner. Suitable systems are in place for testing and maintaining equipment at the home so that it is a safe place for service users and staff. What has improved since the last inspection? What they could do better: Contracts are in place for service users. However these have not been reviewed recently and contain the signature of the old manager. The new manager said that she would be reviewing the contracts shortly. Service users needs are being reviewed by social workers but there remains a need to update people’s care plans so that they contain only current, relevant information, to avoid any confusion about the care and support that people require. There is a need to devise a risk assessment to help staff to remove the possibility of service users being hurt as a result of any challenging behaviour. Overall there is evidence to indicate that service users are supported to venture out into the community regularly, however there is need to keep better records to help the home to monitor and review service users’ needs in this regard. There have been a number of medication / recording errors at the home during the last year, which is unacceptable as it could present risks to service users’ health. Procedures have been bolstered to stop this from recurring. There is need to continue to closely monitor and review the procedures at the home to avoid any further errors and for the locality manager to write to the Commission for Social Care Inspection with the outcome of her investigations into medication errors at the home. The manager has stated a commitment to surveying the views of service users and relatives as part of the home’s quality assurance system. This is an outstanding requirement from the last inspection. Pia - Manor Court Road, 132/4 DS0000004227.V298048.R01.S.doc Version 5.2 Page 7 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. Pia - Manor Court Road, 132/4 DS0000004227.V298048.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 Pia - Manor Court Road, 132/4 DS0000004227.V298048.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): 1,2 and 5 The judgement for this outcome group is good. Suitable information and procedures are in place to sensitively support people to move into the home and to inform them of their rights and responsibilities when they move in and service user contracts are being appropriately reviewed. EVIDENCE: Since the last inspection the home’s Statement of Purpose and service user guide has been reviewed to update information about the home and to make it more accessible to service users. This information is valuable in helping new service users to make an informed choice about whether they would like to live at the home. The current service users have lived together for several years, so no new assessment information was available for inspection on this occasion. An admission policy is in place for the home advising staff of good practices to adopt when new people are referred to the home. The manager explained that she is planning to update the signatures on service users’ contracts shortly to take account of the fact that the previous manager signed the current contracts. The manager said that the other information contained in the contracts would remain the same. Pia - Manor Court Road, 132/4 DS0000004227.V298048.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 The judgement for this outcome group is adequate. Good levels of information are in place explaining service users’ needs and for managing risks, however there remains a need for care plans to be reviewed so that everyone is clear that the advice is all still relevant. EVIDENCE: Each service user has a care plan in place containing very good levels of information regarding their personal routines and likes and dislikes so that staff are able to support people in the way they like. A sample examination o service users records demonstrates that service users needs are being reviewed by social workers. Work has taken place to review three service users’ care plans but there remains a need to review the care plans of five other service users. A team leader explained that the delays in reviewing these documents has been due to the fact that the paperwork format for the care plans is being changed at the same time which means that all the information has to re written. Pia - Manor Court Road, 132/4 DS0000004227.V298048.R01.S.doc Version 5.2 Page 11 The manager has agreed to review the current care plans and record any necessary amendments, to ensure that all the information is still relevant, with a view to changing the paperwork format later. One service user has recently been involved in a number of personal planning meetings with his social worker, relatives and staff of the home, to enable him to contribute to pans for his future care. Comments made by staff demonstrated a good knowledge of service users’ needs. Risk assessments are place addressing a good range of everyday hazards associated with daily life and service users specific health needs, e.g. epilepsy. Comments made by a service user and discussions with staff confirmed that service users are encouraged to take part in their reviews. Some helpful written guidance information has been developed by the home to advise staff on how to respond to behaviour challenges, presented by a service user. This person has also been referred for psychology support and records are being kept by staff to help to identify behaviour triggers and the development of more detailed guidance. There is a need to develop a clear strategy for managing risks to other service users so that staff are clear about when and how to intervene to reduce the possibility of anyone being assaulted in future. Pia - Manor Court Road, 132/4 DS0000004227.V298048.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): 11,13,15,16 and 17 Overall the judgement for this outcome group is adequate. Service users are supported to enjoy a reasonable lifestyle and are provided with meals they enjoy. There is scope for improving the records of activities so that service users’ leisure needs can be monitored and reviewed. EVIDENCE: 6 service users attend day services, including college courses, on a part-time basis during the week and two people stay at home. On the day of the inspection 2 service users were supported to go out for a picnic at Bosworth Park. Examples of activities provided by staff and the manager. One service user commented that he enjoys gardening and attends a horticultural project two days per week. Examples of outings and activities provided by the manager and staff, include, regular shopping trips for personal items and groceries, cafes, cinema, theatre, Civic hall shows, Coombe Abbey and other parks. Pia - Manor Court Road, 132/4 DS0000004227.V298048.R01.S.doc Version 5.2 Page 13 A service user confirmed that he receives support to go shopping and enjoys trips to the cinema. Service users’ records were sampled and discussed with a team leader. This indicated that not all activities are recorded. Good work has taken place to install a spacious new spa pool at the home for service users to enjoy. A track hoist has been fitted to enable a person with physical disabilities to take advantage of this facility. Discussions with staff and responses recorded in relative’s questionnaires confirm that that the home supports service users to maintain contact with family members. Staff are provided with sexuality training to help them to respond appropriately to service users. Service users have been issued with keys to their bedrooms and the front door so that they can exercise some control in their daily lives. Similarly they have been issued with lockable tins for storing their belongings safely. Service users are given small amounts of cash to manage, where appropriate, so that they can exercise some independence over spending their money. The home’s menus indicate that service user have a suitably balanced diet. Service users likes and dislikes are recorded in their files. Fruit is available for service users to help themselves and snack foods, such as crisps, biscuits and yoghurts are also available for service users between meals. Information contained in service users files confirmed that the home makes use of advice and support from the community dietician. A team leader explained that the menus have been checked by a dietician to ensure they are nutritionally balanced and meet people’s needs. Discussions with staff advised that some service users enjoy shopping for groceries. A service user confirmed that he often goes shopping to choose groceries with support from staff. Currently none of the service users have special cultural needs though the manager reports that the home would accommodate specific cultural needs where necessary. Pia - Manor Court Road, 132/4 DS0000004227.V298048.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 The judgement for this outcome group is poor. The home supports service users to receive appropriate support with their personal care needs and to access suitable healthcare support. The rating for this group of Standards is compromised by a recent history poor medication recording practices. EVIDENCE: Service users’ care plans provide good levels of information about service users’ preferred routines and patterns of daily living. This enables staff to be more sensitive to service users’ needs and to support them in the way they prefer. Discussions with staff and the manager confirmed that service users have flexible age appropriate bedtimes and are able to sleep in later in the mornings when they are not going to day services. Service users gender care preferences have been recorded in their files. The home employs two male staff which allows male service users to receive personal care support from men when they on duty. A sample examination of service users’ health records indicates that the home is supporting service users to gain access to advice and support from relevant health professionals, such as psychiatrist, psychologist, dietician and diabetes nurse. A service user confirmed that staff support him to attend regular appointments with a community nurse. Pia - Manor Court Road, 132/4 DS0000004227.V298048.R01.S.doc Version 5.2 Page 15 Service users’ records contain good accounts of the outcomes of health appointments and indicate that service users are supported to access well person checks, medication reviews and GP support, where required. Staff spoke in an informed manner about service users health needs and demonstrated a good knowledge of protocols for the administration of epilepsy and insulin. Staff confirmed that they have received epilepsy and diabetes training. Since the last inspection there have been 4 reported incidents of poor medication record keeping. This is unacceptable practice that could place service users at risk and could be responsible for effecting one service user’s behaviour. At the time of writing this report the locality manager for the service was in the process of investigating this matter. Comments made by staff confirmed that arrangements have been bolstered for monitoring medication more closely and for increasing staff accountability. The member of staff on sleep in duty is now responsible for administering medication and counting the tablets in stock and checking the blister packs to ensure that no medication has been missed and for signing the handover record to confirm that medication is correct. This is backed up by a weekly medication audit by team leaders. Discussions with a member of staff giving out medication, demonstrated a satisfactory awareness of good medication administration practices. Current medication sheets were sampled and seen to contain no errors. Photographs of service users are on file with the medication sheets to avoid anyone being misidentified and receiving the wrong medication by mistake. Pia - Manor Court Road, 132/4 DS0000004227.V298048.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): The judgement for this outcome group is adequate. Suitable training and procedures are in place for dealing with complaints and reporting and investigating suspicions of abuse. One person would benefit from an advocate to represent her interests. EVIDENCE: There have been no complaints to the Commission for Social care Inspection and no complaints have been made directly to the home. A complaints procedure is in place at the home and is summarised in the Statement of Purpose. Illustrated complaints information has also been made available to service users. Staff training records show that abuse training is provided at the home. This was also confirmed in discussions with staff. Comments by staff demonstrated a good understanding of adult abuse issues and for reporting incidents to the manager to follow up. Procedures are in place for notifying the Commission for Social Care Inspection about important incidents and where appropriate the home has referred incidents to social workers to consider under the vulnerable adult procedures. One service user has been hit by another service user with challenging behaviour on several occasions during the last year. There is a need to recruit an advocate for this person to ensure that her needs are independently represented. Pia - Manor Court Road, 132/4 DS0000004227.V298048.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): The judgement for this outcome group is adequate. The home is generally comfortable and homely for service users although improvements are necessary to some décor and carpets. EVIDENCE: There are two lounges in the home. Both rooms are nicely furnished and decorated with comfortable seating for everyone. There is a mix of dining chairs in the downstairs of the home, which needs to replaced with a matching set to provide better dining conditions for service users. The décor in the hallways and stairs is old in need of upgrading and the carpets in these areas are in poor condition and need replacing. The manager reports that there are plans in place for the organisation to address theses matters. Service users bedrooms are comfortable and contain equipment, pictures and other personal belongings that confirm service users have been supported to personalise these areas in keeping with their preferences. The downstairs bathroom has hoisting equipment fitted to enable a service users with physical disabilities to use the bath safely. The ceiling in the upstairs bathroom needs re-painting where it is stained around the edges. Good work has taken place to fit a spacious new spa bath with hoisting equipment for service users to use and relax in. The home has a good sized Pia - Manor Court Road, 132/4 DS0000004227.V298048.R01.S.doc Version 5.2 Page 18 garden at the rear with an attractive patio set, including a parasol for serviced users to sit under in the hot weather. Overall the home is reasonably clean, other than some old stains on the hall carpets, which needs replacing. A modern washing machine has been purchased with a sluice facility and programmed capable of dealing with the small mount of continence laundry at the home. Policies are in place for managing infection control issues and aprons and gloves are situated around the home for staff to use. An action plan (to follow up to locality managers monitoring visit) completed by the manager, noted that action had recently been taken to improve cooker cleaning, indicating that cleanliness in the home is being monitored. Pia - Manor Court Road, 132/4 DS0000004227.V298048.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 The judgement for this outcome group is good. Staff are well trained and appropriately vetted to ensure they are properly equipped for their roles and safe to work at the home. EVIDENCE: The home’s rota was discussed with staff and a team leader. This confirmed that typically the home provides three staff on duty early morning and four in the evening. Staffing provision is also made for service user at home during the day to enable them to enjoy activities at home or in the community. Training information provided by the manager indicates that staff have access to a very good range of training, including mandatory health and safety related training, care courses, management courses and NVQ training. This was confirmed by staff comments, who also confirmed they are currently taking learning disability award framework training to further equip them for their work. There have been no new staff recruited since the last inspection, although two existing employees of the organisation have transferred to the home. The file of the person most recently recruited to the home, Aug 05, was examined. This confirmed that suitable vetting checks and references are taken up by the organisation as part of the recruitment process, to ensure that staff are suitable to work at the home. Pia - Manor Court Road, 132/4 DS0000004227.V298048.R01.S.doc Version 5.2 Page 20 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 The judgement for this outcome group is adequate. Overall the home is appropriately managed and monitored. Improvements are necessary to the home’s procedures for routinely consulting with service users and their relatives so that their views are used to underpin quality assurance at the home. EVIDENCE: The manager of the home has eleven years experience of working with people with learning difficulties and holds the Advanced Management in Care qualification. The manager is also in the process of completing the Registered manager’s qualification to further equip her for her role. The manager stated that she is about to send questionnaires to service users, relatives and day services to seek their views about the service provided by the home. This is an outstanding requirement from the last inspection. The service users’ meeting records show that there have been only two meetings since the last inspection to check if service users had any concerns and to discuss activities and other aspects of life at the home. Pia - Manor Court Road, 132/4 DS0000004227.V298048.R01.S.doc Version 5.2 Page 21 Monitoring visits are routinely taking place by the locality manager responsible for the home. Reports were seen, recording the actions carried out by the manager to address the issues raised in the locality manager’s reports. The pre-inspection questionnaire completed by the manager shows that all the essential health and safety checks are being routinely carried out at the home. Fire records were sampled and demonstrate that fore equipment is being properly tested and maintained and confirm that fire drills are carried out at the home. A landlord gas safety certificate is in place to demonstrate that the gas equipment is safe. Pia - Manor Court Road, 132/4 DS0000004227.V298048.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 x 5 2 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 2 25 x 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 2 3 x 3 x LIFESTYLES Standard No Score 11 3 12 x 13 2 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 3 x 3 x x 3 x Pia - Manor Court Road, 132/4 DS0000004227.V298048.R01.S.doc Version 5.2 Page 23 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 YA5 Regulation 5 Requirement Proceed with pans to review signatures on service users’ contracts following the change of manager at the home. All care plans must be reviewed with the service user at least every six months and updated to reflect changing needs, with agreed changes recorded and actioned. (Old timescale of 01/12/05 extended) Consultation meetings, (house meetings), must be reestablished and held monthly with a record of the meeting maintained. (Old timescale of 30/08/05 not met) Alternatively the manager must keep records of other meetings or individual discussions to demonstrate that service users are being regularly consulted about decisions at the home. Timescale for action 31/07/06 2 YA6 15 31/07/06 3 YA7 12 15/07/06 Pia - Manor Court Road, 132/4 DS0000004227.V298048.R01.S.doc Version 5.2 Page 24 4 YA9 13 (2) (c) 5 YA13 12 (2) (n) 6 YA20 13 (2) Devise a clear risk assessment strategy for staff to effectively manage and reduce any potential risks of service users being assaulted as a result of challenging behaviour. Proceed with plans to work with the advice of psychologists to review the guidelines in place for the service user with challenging behaviour. Keep better records of service users community leisure activities to assist with monitoring and reviewing their needs. Continue to closely monitor medication procedures to avoid any further errors. The Locality manager is required to write to the Commission for Social care Inspection with the outcomes of her investigation into medication errors at the home. Recruit an advocate to represent the interests of the service user who has been assaulted on several occasions during the last year. Make plans to upgrade : - Décor in the hall lounge and ceiling in the upstairs bathroom. - Carpets in the hallways and staircases. The registered manager must ensure that systems identified in the service user guide as being in place for consultation with service users are implemented Old timescale, 30/4/06, not met. 30/07/06 30/06/06 20/07/06 7 YA22 12 (2) 30/07/06 8 YA24 23 (2) (d) 30/07/06 9 YA39 24 30/07/06 Pia - Manor Court Road, 132/4 DS0000004227.V298048.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. Refer to Standard Good Practice Recommendations Pia - Manor Court Road, 132/4 DS0000004227.V298048.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Pia - Manor Court Road, 132/4 DS0000004227.V298048.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!