Inspection on 16/08/07 for Pinfold Lane

This inspection was carried out on 16th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pinfold Lane 24/08/06

Pinfold Lane 06/01/06

Pinfold Lane 08/12/04

Pinfold Lane 03/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Pinfold Lane 1 Pinfold Lane Garforth Leeds West Yorkshire LS25 1HE Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 16th August 2007 09:30 Pinfold Lane DS0000001491.V345311.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 Pinfold Lane DS0000001491.V345311.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. Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinfold Lane Address 1 Pinfold Lane Garforth Leeds West Yorkshire LS25 1HE 0113 2863691 F/P 0113 2863691 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) www.c-i-c.co.uk. Community Integrated Care vacant post Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th August 2006 Brief Description of the Service: Pinfold Lane is a detached house situated close to the town of Garforth. It has an enclosed garden to the rear of the building. There is parking for two cars at the front of the building. Local shops and the town centre are within easy access. Pinfold Lane is part of the Community Integrated Care organisation, and is registered to provide personal care for up to 4 people with learning disabilities. The accommodation consists of four single bedrooms, a lounge and separate dining room, shower room and bathroom, laundry, and a domestic style kitchen/diner. All laundering is undertaken on the premises. The home has a vehicle, which is regularly used by people who live at the home. Details of the fees charged was not available therefore it has not been possible to publish how much a placement costs per week. Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over two days because on the first day of the inspection, people who live at the home were at day services and staff went out to do shopping for the house. One inspector carried out the first site visit between 9.30am and 11.00am and the following day went at 9.00am and finished at 1.30pm. During the inspection process all of the key standards were looked at to try and find out what it was like to live at the home. The last key inspection was carried out in August 2007. An annual quality assurance assessment (AQAA) was completed by the home and this information was used as part of the inspection. Surveys were sent to relatives and healthcare professionals. Three surveys were returned by relatives, one survey was returned by a healthcare professional and their responses have been included in the inspection report. One survey was received from a person who lives at the home, their response has also been included in the report. Feedback was given to the manager at the end of the visit. During the visit the inspector looked around the home, spoke to staff and the manager. People who live at the home have complex needs and communication is very limited. One person was able to talk about the care they receive. Interaction between staff and the people who live at the home was observed. Care plans, risk assessments, healthcare records, meeting minutes, and staff recruitment and training records were looked at. What the service does well: One person who lives at the home completed a survey. At the inspection, they said they would like their responses to be included in the report. The following are a sample of their responses and comments: • I like living here • I feel well cared for • The staff treat me well • I like my bedroom • I like the food • I love having a long bubbly bath • I like playing the keyboard • I want them to take me to another show • It’s great when staff take me to the beautiful octopus • I can’t wait to go on holiday Relative surveys were very positive. They said the care home always meets the needs of the people who live at the home and they were always kept up to date with important issues. Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 6 All staff said they thought the home provided very good care. Comments included: • We always try to find out what people want • We treat the house and guys like everyone else in our lives • They experience life as much as other people • People who live here have fantastic lives • We look at each person individually Care plans are very good and focus on what is important to the person. They explain what people like and dislike and provide guidance on interpreting the actions of each person. People who live at the home have a good lifestyle and have lots of opportunities to do different things. The home has good systems in place to make sure health and personal care needs are met and people who live at the home get the right support from healthcare professionals. Staff receive good training opportunities, which equips them with the knowledge and skills to do their job properly. What has improved since the last inspection? What they could do better: People who live at the home or their representatives do not have contracts that provide them with details of the terms and conditions of their stay or information about how much their placement costs. The daily records provided a lot of positive evidence but some of the wording was inappropriate and written in a way that does not appear to respect the people they were writing about. There were several entries that referred to people as ‘demanding of staff attention’, ‘very demanding of staff’, ‘quite attention seeking’, ‘well behaved’. One entry stated ‘of course promptly told to take them back- small paddy’. Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 7 The decoration in two bedrooms was unsatisfactory. Paintwork and woodwork looked grubby and it was evident that these areas had not been decorated for some time. The carpet in one room was stained and the bed was broken. One bedroom did not have any curtains; staff said they were waiting for the curtain rail to be repaired. There was an odour in one bedroom. The settees in the lounge were in a poor condition and must be replaced. The home has not had a registered manager since May 2006. A registered manager’s application was sent to the current manager in August 2006 but the application was not returned. The manager agreed to submit an application as soon as possible. Requirements and recommendations to address the shortfalls have been made and appear at the end of the report. 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. Pinfold Lane DS0000001491.V345311.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 Pinfold Lane DS0000001491.V345311.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Previous inspections and procedures indicate that a thorough admission process is carried out to make sure the home can meet the needs of people who move into the service. People do not have access to all the information about placements they are entitled to have. EVIDENCE: Everyone has lived at the home since 2005 so there was very little recent evidence for many aspects of this outcome group. The admission process was looked at during previous inspections and the relevant National Minimum Standards were met. The AQAA stated since the last inspection, the home’s statement of purpose and service user guide has been stored on the computer, which enables easy access and easy updating. Each person should have been issued with a statement of terms and conditions and information about how much is charged for each placement. This information was not available at the inspection. The manager contacted the organisation’s finance section for details of the fees charged and they agreed to send the information to the home. Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Everyone works hard to make sure people who use the service receive person centred care and are supported to achieve their personal goals, which help maintain and develop skills. EVIDENCE: The AQAA stated each person has an Essential Lifestyle Plan (ELP) or care plan. The ELP is the chosen method for representing the views of people who live at the home as this method draws in the views of the maximum number of people who have an interest in the person. They state they chose this method because three people who live at the home are non-verbal and cannot self advocate. Three people’s care records were looked at. Each plan had very good information about how care needs should be met and potential risks. Records explained what people liked and disliked. For example, one section of the plan Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 11 asks who is the person? The plan then provides very specific details about them, i.e. loves a laugh, likes quality time listening to music. Plans also provide guidance on interpreting the actions of each person. One plan stated that the person might take their supporter by the hand, which may indicate they want to go out. Plans also focused on what is important to the person. One plan stated their ‘parent is a key person in their life, when they visit we need to make them especially welcome’. All staff said they thought the home provided very good care. Comments included; • We always try to find out what people want • We treat the house and guys like everyone else in our lives • They experience life as much as other people • People who live here have fantastic lives • We look at each person individually The AQAA stated the home ‘has adopted a rotational system for key working which allows long term continuity for those they support whilst keeping all staff abreast of the continuing and changing needs of those they support’. The AQAA stated people who live at the home attend staff meetings and regularly interview job applicants. Staff at the home said the care plans are good because they give everyone a really good picture of the person. One staff said everyone tries very hard to think of what each person would like to do and this is included in their care plan. Pinfold Lane DS0000001491.V345311.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who live at the home have a varied and fulfilling lifestyle that is based on their wishes and individual needs. People’s rights are clearly promoted but written records do not always reflect this. EVIDENCE: One person who lives at the home completed a survey. At the inspection, they said they would like their responses to be included in the report. The following are a sample of their responses and comments: • I like living here • I feel well cared for • The staff treat me well • I like my bedroom • I like the food • I love having a long bubbly bath • I like playing the keyboard Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 13 • • • I want them to take me to another show It’s great when staff take me to the beautiful octopus I can’t wait to go on holiday Surveys from relatives were positive and the following are a sample of responses and comments: • The care home always meets the needs of their relative • They were always kept up to with important issues • The care home gives the support that they expect • The manager and staff are brilliant people and good to talk to • They are efficient in meeting physical care needs • They support the individual giving attention to preferences and social and emotional needs • Under the ‘how do you think the care home can improve, one relative wrote ‘just be the way they are now, they are all very nice people’. When asked what the home does well, staff said they are good at making sure people go out regularly and have opportunities to go on different outings. Staff said they thought everyone who lives at the home had a good quality of life. Staff also talked about the flexibility of the service and said people choose when to go to bed and when to get up, although things tend to be more organised during the week because people go out during the day. The AQAA stated under the what do you do well section, the home supports and encourages people who live at the home to be prominent and active community participants, discover additional and alternative leisure activities, be aware of their rights and respect these and be aware of and accept their responsibilities. The daily records for three people, covering a four-week period, were looked at. There was evidence that people had an active lifestyle, family contact, and health appointments. Recreational activities included trips to the town centre and local pubs, clothes shopping, and an outing to Temple Newsam. People who live at the home have different day care packages, which range from 1½ days attendance to 5 days attendance per week. Staff said day time activities provided people with variety and gave them the chance to meet lots of other people. Two staff had recently taken one of the people who live at the home on a camping trip. Staff said this had been very successful and the person had thoroughly enjoyed it. The home has just bought some camping equipment; the manager said they are hoping to organise similar trips involving other people who live at the home. Everyone who lives at the home is going on holiday to Cornwall in September. Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 14 The daily records provided a lot of positive evidence but some of the wording was inappropriate and written in a way that does not respect the people they were writing about. There were several entries that referred to people as ‘demanding of staff attention’, ‘very demanding of staff’, ‘quite attention seeking’, ‘well behaved’. One entry stated ‘of course promptly told to take them back- small paddy’. The AQAA stated since the last inspection a dietician has reviewed the home’s menu and recommendations to improve the menus were implemented. One week’s menus were looked at. There was a good variation of food and the meals were nutritionally balanced. Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 15 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home has good systems in place to make sure health and personal care needs are met and people receive the right support from healthcare professionals. EVIDENCE: Each Essential Lifestyle Plan provided very good information about all aspects of personal care. There were details of preferences and routines, all of which were written in a way that promoted person centred care and independence. The AQAA stated the home has improved since the last inspection because all staff have attended medication competency training and one day training provided by pharmacy. Under the section ‘what we do well’ the AQAA stated ‘ensure the safe handling of medication’. Staff talked about arrangements for healthcare and said they were good at involving healthcare professionals and seeking advice and guidance. Examples were given when they had involved speech therapists, dieticians, and specialists. Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 16 A healthcare survey stated the care service does well and has always responded appropriately if concerns have been raised. Staff cut the toenails of people who live at the home, although they have not received any training. Two people apparently move a lot when their nails are being cut. A professional or someone who has received appropriate training should carry out this practice because it can lead to complications if toes are damaged during the process. Medication and medication records were looked at and the amount of medication and the records corresponded. Medication storage was looked at and the medication was well organised. The manager said staff have to complete medication training before they can administer medication. Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 17 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. We have made this judgement using a range of evidence, including a visit to the service. Systems are in place to protect the people who live at the home. EVIDENCE: The manager said the home had not received any complaints since the last inspection. Information about making complaints was available in the home. Relative surveys stated they knew how to make a complaint if they were unhappy with the care provided. Staff said they talk to the manager if they have any concerns. Staff and the manager have attended No Secrets training. The manager said this is up dated every twelve months. Personal allowance records were looked at. All financial transactions were recorded and receipts were obtained for any purchases made. Two people’s monies were counted and the amount corresponded with the amount on the balance sheet. The home has a vehicle and people at the home make a financial contribution. Each person has an agreement for the vehicle, which includes details of payments. Each person makes an additional contribution for fuel, which is distributed equally. Transport records confirmed that the vehicle was used regularly however they do not identify which people have travelled in the Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 18 vehicle. This information should be recorded to make sure everyone is using the vehicle and getting value for money. Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 19 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, 26, 27, 28 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is clean and well maintained and people who live there are comfortable in their surroundings. EVIDENCE: A tour of the building was carried out. All areas of the home were seen. It was clean and tidy and generally odour free. There is an enclosed garden that people who live at the home regularly use. There are four main communal areas, kitchen/diner, dining room, lounge and conservatory. All are domestic in style. Staff said people spend a lot of time in the lounge and kitchen but very little time in the conservatory, and the dining room is not used at all. There are plans to make the conservatory into a sensory/music room; staff said this would be beneficial to everyone living at the home. Staff also spoke about plans to change the dining room into a bedroom and then change a bedroom into an office or quiet lounge. The Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 20 manager agreed to discuss proposals with the Commission before reducing the amount of communal space. Since the last inspection the lounge and a bedroom has been decorated, and the hall, stairs and landing carpet has been replaced. Staff said a new carpet shampooer has been purchased and carpets are regularly cleaned. The lounge has been decorated. The conservatory has a new roof and replacement windows. Many areas looked quite bare and only a few pictures and photographs were displayed around the home. Staff said people who live at the home sometimes remove items from the wall but acknowledged if they were fastened securely this would not be a problem. Staff talked about putting more pictures and photographs on the wall and generally making it more homely. The decoration in two bedrooms was unsatisfactory. Paintwork and woodwork looked grubby and it was evident that these areas had not been decorated for some time. The carpet in one room was stained and the bed was broken. One bedroom did not have any curtains; staff said they were waiting for the curtain rail to be repaired. There was an odour in one bedroom. The radiator guard in the upstairs toilet was damaged and rusty and some tiles were cracked. The settees in the lounge were in a poor condition and must be replaced. Pillows in one bedroom were very stained. This was pointed out on the first day of the inspection; on the second day of the inspection these had been replaced. There was a supply of disposable gloves, wipes, anti bacterial hand wash and paper towels throughout the home. The laundry had an industrial washer with a sluicing facility and a dryer. Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who live at the home are supported by a skilled staff team. Good support systems are in place and everyone receives good training opportunities, which equips them with the knowledge and skills to successfully perform their duties. EVIDENCE: All staff said they thought the home provided very good care. Comments included; • We have a good staff team • It’s a great atmosphere • Everyone is very friendly • Staff have good training opportunities • We get regular supervision and good support One person who had worked at the home for a year said she had received very good support, had completed several good training courses, including training that covers how to provide good care. Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 22 Staff were asked about staffing levels. Everyone said they thought the staffing levels were appropriate and they had enough time to carry out their duties and meet the needs of the people who live at the home. Staff said extra staff are available if they organise outings or if people who live at the home are unwell and require additional support. This also applies to night cover. The home has struggled with staff shortages for some time but two new staff have recently started work and three staff are hopefully starting soon. Staff were looking forward to having a full staff team and said this will make a big difference. The AQAA stated staff are comprehensibly trained in recognising and challenging discrimination. It also states that 3 out of the 7 care staff hold an NVQ in care at level 2 (qualification) or above. A training matrix was looked at and this confirmed that staff had received regular training, which included safe working practice training, person centred training, principles of care and medication competencies. Recruitment records were looked at for two people who recently started working at the home. All the information that is required before a person can start work had been obtained. Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 23 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is well managed but the absence of a registered manager leaves the service vulnerable putting people at potential risk because it does not have a person who is accountable for managing the service on a day to day basis. EVIDENCE: The manager has managed the home for eighteen months. He talked about promoting person centred care and had good knowledge about each person who lives at the home. Staff said they received good support from the manager. The home has not had a registered manager since May 2006. A registered manager’s application was sent to the current manager in August 2006 but the application has not been returned. The manager said he had sent it to the Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 24 Commission several months ago. The manager agreed to submit an application as soon as possible. The manager has started his registered manager’s award and hopes to have it finished by May 2008. The last recorded accident/incident form was completed in April 2007. Daily records provided evidence that in the last few weeks there had been several incidents which had resulted in minor injuries, including red mark on face and cream was applied, and mark on nose. Incidents that were not recorded on an accident form related to the same person. The manager agreed to look at recording of incidents to make sure they could be properly monitored. Once a month the registered provider should arrange for a member of the management team to visit the home and look at the general conduct of the home, these visits are called Regulation 26 visits. The manager said these visits were always carried every month, and generally by the area manager. The report from May 2007 was looked at and this contained good detail on the conduct of the home but reports from June and July were not available. The manager said each person who lives at the home has an annual individual review meeting, which looks at how well the home is meeting the needs of the person. The manager was not aware of any questionnaires or surveys that are sent out to obtain views of people living at the home or connected to the home. He agreed this could be an area to develop. Health and safety records confirmed that staff received micro fire training in February, March and May 2007. Portable appliance tests were completed in February 2007. Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 25 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 1 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 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 26 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 YA5 Regulation 5 Requirement The registered person must ensure people have a statement of terms and conditions. A record of the current range of fees must kept in the home. This will make sure people have access to information about their placement. When staff are writing daily records they must make sure the records are appropriate and demonstrate that people who use the service are treated with respect. This will make sure their rights are fully recognised The home must be reasonably decorated to make sure people live in a pleasant and safe environment. The person acting as manager of the home must make an application to become registered. This will make sure the home has a person who is responsible for the day to DS0000001491.V345311.R01.S.doc Timescale for action 31/10/07 2 YA16 12 30/09/07 3 YA24 23 31/10/07 5 YA37 CSA 11(1) 30/11/07 Pinfold Lane Version 5.2 Page 27 7 YA39 24(1)(a and b) day running and is accountable to the Commission. The registered person must establish and maintain a quality monitoring system for the quality of care provided at the home, based on seeking the views of people who are involved in the service. (Timescale of 22/01/07 not met) 30/11/07 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 Refer to Standard YA19 YA23 Good Practice Recommendations People should be suitably trained to cut toenails before they cut the toenails of the people who live at the home to make sure they do not put the health of people at risk. Their should be a record of who has travelled in the home’s vehicle so usage can be monitored to make sure people who pay towards the vehicle are getting a fair service and value for money. The manager should be suitably qualified to make sure they have the knowledge and skills to manage the service. All accidents and incidents should be recorded in a way that enables proper monitoring of accidents and incidents to take place. 3 4 YA37 YA41 Pinfold Lane DS0000001491.V345311.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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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