Inspection on 18/08/08 for Poplars

This inspection was carried out on 18th August 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Poplars 04/07/07

Poplars 26/07/06

Poplars 27/10/05

Poplars 25/05/05

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 27/02/2009.

CARE HOME ADULTS 18-65 Poplars 123 Regent Road Hanley Stoke on trent Staffordshire ST1 3BL Lead Inspector Wendy Jones Key Unannounced Inspection 18th August 2008 12:50 DS0000064016.V370233.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 DS0000064016.V370233.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. DS0000064016.V370233.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Poplars Address 123 Regent Road Hanley Stoke on trent Staffordshire ST1 3BL 01782 209410 01782 269187 stoke.enquiry@caretech-uk.com 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) Delam Care Ltd Post vacant Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1), Mental disorder, excluding of places learning disability or dementia (6) DS0000064016.V370233.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. We are covered by MD but need to able to accept a person with a mental illness who is over 65. 4th July 2007 Date of last inspection Brief Description of the Service: The Poplars is a six-bedded care home owned by Delam Care Limited, a company owned by Care Tech. The Poplars is in an urban area close to Hanley park and Stoke on Trent College and in close proximity to similar care homes owned by the same company. It is located within a twenty-minute walk to the shopping and leisure facilities of Hanley. The Poplars provides a service to six people of either gender with a learning disability although some may also have mental ill health. The home is one of 3 services all managed by the same manager. The homes have their own core staff members but absences and staff vacancies are covered by staff from the other homes or from other staff from within the company. The people using the service access a range of college courses and undertake social activities and holidays. The organisation has another three homes in the immediate area and between them they have the use of two people carriers and the people using the service contribute to the running of these vehicles. There is one care staff member on duty at all times and the aim is to provide service users with support, encouragement, supervision and monitoring in order to enable them to live as independent a life as possible. Information about the range of fees and the costs of the service are not available in the Service user guide. Prospective service users and their supporters should contact the provider for this. DS0000064016.V370233.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate, quality outcomes. This was a key inspection site visit of this service undertaken on 18 August 2008 and included formal feedback to the deputy manager. In total the visit took approximately 04:00hours. The purpose of this visit was to assess the services performance and to establish if it provides positive outcomes for the people who live there. The visit included checking that any requirements and recommendations of the previous inspection visit of 04/07/07 have been acted upon; looking at information the service provides for people who may use the service, their carers and any professionals; looking at information that the service provides to people who use the service to ensure that they understand the terms and conditions under which they have agreed to live at the home and the fees they should pay. Other information checked included assessments and care records, health and medication records; activity and records relating to the menu’s, finances, staff training and recruitment, complaints and compliments, fire safety and health and safety checks. The deputy manager, staff and people who use the service were spoken to during the site visit and a brief tour of the building was undertaken. Before the visit began, the service provided it’s own assessment of its performance, in the form of an Annual Quality Assurance Assessment (AQAA). Surveys were sent out to people who use the service, relatives and staff and any professional that has involvement in the service. We have received five service user surveys; their comments are included in the main body of this report. We made 9 recommendations as a result of this visit. Two requirements that have not been met from the previous inspection have been repeated as recommendations. This is due to changes in our guidance about when requirements are to be made. What the service does well: Assessments are carried out on all people who may use the service and professional assessments are also sought to ensure that the service can meet the needs of people who may use the service. DS0000064016.V370233.R01.S.doc Version 5.2 Page 6 Care plans and risk assessments are developed for all of the people using the service, they are reviewed regularly and most of the people who use the service are involved in discussions about them. Meetings are held with the people using the service to discuss routines and matters that affect them and are important to them. The financial arrangements for the people using the service are safe and robust. Generally the people using the service are able to choose how they spend their day. Independence is encouraged as much possible. Each person has their own bedroom and they are encouraged to personalise them. Keys to the house and bedroom are available if people choose to have them. People using the service are supported to access the health services and are supported with appointments. There have been no complaints made about the service in the last twelve months either to the Home or to us. People who use the service say they are happy living at the Poplars. Staff recruitment procedures are robust and protect the people using the service. What has improved since the last inspection? What they could do better: The costs and fees of the service should be included in the service user guide, and both the guide and the statement of purpose should be reviewed to ensure that it provides up to date information for both people who use the service and those who may want to. Both documents should be produced in a format that is user friendly. DS0000064016.V370233.R01.S.doc Version 5.2 Page 7 More work is required to ensure that the Home is able meet the complex and diverse needs of people who use the service. This includes staff training and more comprehensive care planning. Staff must be trained in the Protection of Vulnerable Adults to ensure that they know how to recognise and protect people from abuse and how to report it. They should receive training to ensure that the diverse needs of people who use the service are met. There is a need to keep staffing levels under review, to ensure that sufficient staff are available to support service users on activities when out of the home. The person centred planning model should be implemented to ensure that people using the service are fully involved in making decisions about their lives. The service should continue with the maintenance and redecoration programme that it has started to ensure that the people using the service live in a well maintained and comfortable home. The front garden and main entrance to the service should also be improved, as it is currently unkempt in appearance. The provider should ensure that the manager of the service applies to us to be registered and approved. 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. DS0000064016.V370233.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 DS0000064016.V370233.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who may use or do use the service cannot be sure that the information about the service is up to date and provides them with the information they need to make a decision about the home. This means they cannot be sure that it can meet their needs. EVIDENCE: The service told us in the AQAA that they carry out, “Assessment of prospective clients. Invite them to the home for short visits and/or a meal. Provide time to meet with other service users. Service users are aware of their rights and responsibilities through the provision of a contract supplied by home and by funding authority. Service users have a copy of the service user guide, including a copy of the complaints procedure in a written and pictorial format.” At the last key inspection site visit we required the service to make changes to the service user guide and contracts within a given timescale, we also recommended that a review of the statement of purpose and service user guide be carried out. Information provided during this visit indicates that these matters have not yet been completed. Staff said that the manager is currently reviewing the statement of purpose and guide but are not sure if people who use the service have a copy of the guide. We spoke to a person who didn’t know what the guide was. DS0000064016.V370233.R01.S.doc Version 5.2 Page 10 No new admissions to the service have taken place since the last key inspection site visit. A sample of care records show that thorough pre admission assessments had been carried out, and professional in put from social workers and health workers has been sought. People who use the service are happy at the home, “ I like the Poplars, I moved here from another home.” DS0000064016.V370233.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service cannot be sure that the service meets their diverse needs or cannot be confident that the care plans that are in place are current. This means they cannot be sure that the care delivered is appropriate. EVIDENCE: At the last key inspection we were told that person centred planning had been introduced, but the evidence of this visit is that there is little progress in this area. Care planning is not of a good standard, all the plans we saw are not dated, so we don’t know when they were started. There is evidence of reviews of care plans but as previously stated they should be improved. As at the last inspection site visit, there is poor care planning in relation to people who have diverse needs with little explanation of how these needs can be met. In one example we saw that the service is failing to meet the diverse needs of a person who is deaf and have not acted upon the recommendations of the last report to provide appropriate training for staff. It is understood that DS0000064016.V370233.R01.S.doc Version 5.2 Page 12 this person uses British Sign Language; none of the staff have received this training. We are informed that people who use the service meet with their key worker to discuss their care and their plans, these talk time sessions are recorded. The evidence of this visit is that they are taking place with one exception. Staff said, “ because of one persons hearing loss we struggle to communicate with her although she will let you know by gesture what she wants. We haven’t completed any 1:2:1’s or (talk time) with her because of this.” Risk assessments are in place where necessary. Fire safety risk assessments have been carried out for each individual. DS0000064016.V370233.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service are supported to live an independent lifestyle, but limits are evidenced and person centred approaches could be improved. EVIDENCE: The service has told us in the AQAA that; “We provide opportunities for service users to partake in educational and leisure pursuits. Maintain links with family and encourage friendships within the home and surrounding homes. We support and encourage regular community access and use of local facilities.One service user workers on a voluntary basis at a local drop in centre and has done for some time. Service user reguarly access local community facilities such as the banks, library, the museum, the cinema and the park which is in close proximity to the home.” People who use the service told us, “In the week I go out to college. I like to go shopping, staff come with me when I go out.” DS0000064016.V370233.R01.S.doc Version 5.2 Page 14 The service has access to two mini buses, which are shared with other services in the locality, and all service users have bus passes for public transport. Holidays are organised on an annual basis, historically these have been for the whole group of people who use the service, and further thought should be given to promoting the person centred ethos that the service has said it is committed to. People contribute to the costs of the people carrier, it is unclear from the information we saw if this is reviewed on a regular basis. The service should clarify this. We looked at a sample of activity records for the month of June, these show that four people have been to college for two or three days per week, three people had been to the theatre, one has been to the shops, two people had been out on bikes on one occasion and one person has been fishing. In house activities for the same period show that, three people have been involved in beauty and manicure sessions, two people have enjoyed and have been involved with baking and card making, one person enjoys jigsaws and has been involved on two occasions, one other likes to complete word games and soduku puzzles. Previous inspection visits have discussed staffing levels and the affect on people being able to participate in activities, in a spontaneous way. This remains a concern. Although people who use the service have not commented on this during this visit. We talked to people who use the service about their routines and found that they are able to exercise choice in relation to waking and retiring, and what they do during the day. They said that the meals are good, “we can choose our meals.” We looked at the menu and saw a varied diet and choice is available. “Food is alright we have what we want to.” A diabetic diet is provided for one person. We have been told that people decide on the menus at weekly meetings, but these are not recorded. DS0000064016.V370233.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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that the service supports them to have their health needs checked and monitored. And can be sure that their medication needs are met but deficiencies in the health plans potentially place them at risk. EVIDENCE: The service told us in the AQAA that, “Personal support is provided in a manner that ensures privacy, dignity and promotes independence, allowing choice and flexibility. Physical and emotional health needs are met and independence is promoted. Service users are supported in meeting their medication needs and with self medication where assessed as appropriate. The home is currently changing to the Boots medication System and all staff have been trained.” People who use the service require little support with their personal care requiring mainly encouragement and prompting. DS0000064016.V370233.R01.S.doc Version 5.2 Page 16 The records show people who use the service are supported to access health services, including dental, chiropody and the GP on a regular basis. There is evidence that the service works well with health professionals and specialist health services such as psychiatry, mental health and psychology services. In one example staff said that when a hearing impaired person needs to attend hospital appointments, they access a support group, “ Deaf Link” for an interpreter to attend the appointments with her. A sample of care records show that some information in them is not current and in one sample the plans around dental care are incorrect and we couldn’t find a plan for a person who has diabetes This potentially puts people at risk. Health Action plans, which are linked to the person centred planning model, that we are told is being introduced are not in place. The systems for the safe management, storage and recording of medication are satisfactory; records show good practice in this area. We have been told that all staff have received training in the administration of medication and are/have been assessed as competent. A new medication cabinet has been installed. None of the current service user group self medicate. DS0000064016.V370233.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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service know how to make a complaint and who to go to. But they cannot be confident that all staff know how to recognise and report abuse this potentially places them at risk. EVIDENCE: The service told us in the AQAA that, “We promote the individual’s safety in their own home. We encourage the service users to express their views and concerns which are listened to and acted upon.” People who use the service said, “I don’t have any complaints, if I did I would tell my key worker.” “ When I have been unhappy, the staff have helped me.” A complaints procedure is on display in the home, but needs updating. We have been told that the complaints procedure is also being produced in a pictorail format. We have not received a complaint about this service and are not aware that any safeguarding referrals have been made since the last inspection. Staff said that safeguarding training had been arranged but had been cancelled, this is an issue raised at the last inspection visit as a concern. The organistion should ensure that staff have been provided with the training and guidance about recognising and reporting abuse. DS0000064016.V370233.R01.S.doc Version 5.2 Page 18 We looked at the financial records of two people, they correspond with the amounts stored in the home. Finances are checked by staff at every handover and people who use the service sign their sheets when they have money. We are told that financial support plans are in place. We did not check the recruitment records during this visit but understand that the procedures are robust and appropriate pre employment checks are carried out, these include Criminal Records Bureau checks, (CRB) and references. DS0000064016.V370233.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can now be confident that action is being taken to improve the environment, this ensures they live in a well maintained and comfortable home. EVIDENCE: The service told us in the AQAA that, “We provide a homely, domestic and comfortable environment for the residents which promotes their independence and meets their needs. All service users are encouraged to personalise their bedrooms.” Since the last inspection site visit a number of improvements have been made to the environment these include; refurbishment of lounge area, new kitchen work tops, a new dining suite, the cellar has been drained and work carried out to reduce flooding. One bedroom has been redecorated and has a new carpet and sink/vanity unit fitted. Improvements to the hot water supply to the upstairs toilet. The upstairs bathroom has been redecorated and a new bath DS0000064016.V370233.R01.S.doc Version 5.2 Page 20 and sink and new flooring fitted. The shower room has been redecorated and a new shower cubicle and flooring fitted. Paper towel and soap dispensers have been installed in bathrooms and toilets to improve hygiene standards. We are told that the service now has a contract with a gardener to maintain hedges and tidiness. We have also been provided with a copy of the maintenance programme for the home that outlines the further improvements to be made. The list is quite extensive, but we are pleased to note that the organisation is now taking action to improve the quality of the environment for service users. We noted that the home is clean and tidy, warm and comfortably furnished. A service user said, “ the hall and landing need painting.” The service provides all single bedrooms but none have en-suite, it also provides bathing, shower and toilet facilities in sufficient number for the service users. Communal facilities include the lounge, separate dining room and kitchen. We saw one persons bedroom, this was personalised and had been redecorated to the individuals taste. DS0000064016.V370233.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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service must be sure that staff team has received the training they need to deliver care appropriate to their needs. And that the staff team receive regular supervision. EVIDENCE: The service told us in the AQAA that, “ we provide good quality carers to support aspirations and needs of individuals within the home. Staff receive a thorough induction programme, regular supervision that ensures clarity of understanding of roles and responsibilities. Training needs are identified which ensures that both mandatory and knowledge and skills training is achieved.” We looked at the staff rota’s, this shows that one member of staff is deployed during the waking day and one sleeps in during the night. The shift patterns are from 7:30am-4pm and 3.45pm-10pm. Sleep in. The service has four care staff plus the manager who has responsibilty for two other houses. We are told that the service has no staff vacancies at this moment in time. At previous inspection site visits we have discussed the staffing levels and the potential for limiting spontaneous activities for service users. This remains a concern. DS0000064016.V370233.R01.S.doc Version 5.2 Page 22 Staff meetings are planned monthly, the records we saw didn’t show this has happened. Staff supervisions are also planned monthly, but some staff haven’t had a supervision session for sometime, this should be addressed. We are told that 3 care staff have been trained to National Vocational Qualification (NVQ) level 2 and above, this exceeds the recommended minimum standards. All staff have been trained in infection control since the last inspection site visit. All have basic food hygeine and fire training and all have rceived training in the administration of medication. The service should ensure that all staff have been trained to recognise and report abuse (safeguarding training), that all staff receive training relevant to meeting the needs of people with diverse needs, this includes British Sign Language (BSL), diabetes and person centred planning. We have been told that the service has a training matrix which the manager uses to record, monitor and plan staff training, but this wasn’t available during this visit. Recruitment files were not looked at during this visit as we didn’t have access to them, but we look at these records at the organisations head office. Our last report shows that the recruitment procedures are robust and that people who use the service are protected by them. DS0000064016.V370233.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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service are involved in the organisations efforts to continually develop the service and can be confident that they are protected from unnecessary risk. But failure to ensure that areas of concern identified at the last key visit have been satisfactorily addressed mean that they cannot be confident that the service acts in their best interests. EVIDENCE: The service told us in the AQAA that, “Residents benefit from a well run home, with a competant and accountable management structure, that promotes their rights and best interests, which are safeguarded by the homes record keeping policies and procedures.” We know that since the last key inspection visit the service has employed a new manager for the service. We have been told that the new manager has DS0000064016.V370233.R01.S.doc Version 5.2 Page 24 experience in managing residential care service, has a NVQ at level 4 and has completed the registered managers award. We have not yet received an application to register and approve the current manager, this should be forwarded to us with out delay. Additional information in the AQAA states that the equipment in the home is serviced regularly and policies and procedures are also reviewed. We checked a sample of records and saw that fire safety risk assessments have been carried out for each person. At the last inspection we discused the need for an alerting device for the person who is hearing impaired. Staff told us at this visit, that some things had been tried but have proved to be unsuccesful. The service have instead produced a flash card which staff use to alert the individual in the event of a fire, we saw that this is recorded in the risk assessment. The flash card is located on the bedroom door. Deficits in staff training and frequency of supervision, poor quality care plans and failure of the service to meet the needs of people with diverse needs are of concern. Some of the matters we discussed and asked the service to address at the last key inspection visit have not yet been completed. We will continue to strongly recommend that action is taken to ensure these all of the items we have identified are dealt with without delay. We have previously discussed the need for the service to formalise the way in which the service is audited and the the way it seeks the views of people who use the service and other stakeholders on the quality of the service. The organisation has recruited a manager to undertake this task. Staff said that audits are being undertaken and where deficits are identified action is required within specified timescales. Information from these audits will inform development plans for the service. The introduction of a service user forum for the services located in Stoke-onTrent is reported to be successful, representatives from each of the services attend these meetings to share their views and raise any concerns on behalf of each home. Again this information will be used to inform the annual development plans for each of the services. DS0000064016.V370233.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 2 2 3 3 x 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 2 3 X LIFESTYLES Standard No Score 11 x 12 3 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 x 2 X 3 X X 2 X DS0000064016.V370233.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The Statement of Purpose and Service Users’ Guide should be developed in formats, which can be understood by the people using the service, to ensure that they have access to the information they may need. The service user guide should include the range of fees and any additional costs service user can expect to pay, this includes cost of the mini buses. It is recommended that the care plans are developed to ensure that the complex and diverse needs are fully explained and information available to staff as to the individual support required. More work is required to ensure that care planning is based on individual needs, wishes and aspirations. The implementation of person centred planning should be considered. Consideration should be given as to how the people using the service who have diverse needs can be further enabled and supported to be involved in making decisions and DS0000064016.V370233.R01.S.doc Version 5.2 Page 27 2. 3. YA1 YA6 4. YA6 5. YA7 6. 7. 8. 9. YA14 YA37 YA23 YA35 informed choices. The people using the service should be offered the opportunity to enjoy spontaneous, individual activities. The provider should ensure that the current manager applies to us to be registered as a fit person to manage the service. The provider should ensure that staff are provided with training to recognise and report suspected abuse to ensure the welfare of people who use the service. The manager should ensure that staff training is applicable to the needs of the people using the service so that they can fully support them with their specific needs. DS0000064016.V370233.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT DS0000064016.V370233.R01.S.doc Version 5.2 Page 29 DS0000064016.V370233.R01.S.doc Version 5.2 Page 30 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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