Inspection on 08/08/06 for Raynel Drive

This inspection was carried out on 8th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Raynel Drive 20/04/05

Raynel Drive 01/09/04

Raynel Drive 04/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Raynel Drive 9 Raynel Drive Ireland Wood Leeds LS16 6BS Lead Inspector Ann Stoner Key Unannounced Inspection 8 & 9th August 2006 10:00 th Raynel Drive DS0000033820.V303206.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 Raynel Drive DS0000033820.V303206.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. Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Raynel Drive Address 9 Raynel Drive Ireland Wood Leeds LS16 6BS 0113 2678042 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) Leeds City Council Department of Social Services Mr Joseph Bernard Doyle Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: Raynel Drive is a detached house, with five single bedrooms, providing short term and respite care for young adults with a learning disability. In order to cater for individual need, the service can be booked either weekly or on a flexible basis for a weekend or part weeks. The home is situated in north Leeds near to local shops, public houses, several churches and a sports centre. The bus routes, with nearby bus stops, run to Leeds City Centre, Horsforth and Otley. The accommodation consists of a bathroom and shower room, kitchen, lounge and a dining room. There is a separate laundry room. Service users are encouraged to make full use of the facilities in the house and garden, which include a television, DVD player, music system and a greenhouse. On the 15th August 2006 the manager confirmed that the fees ranged from £7.09p to £8.76p per night. The home keeps copies of previous inspection reports in the office, which means that they are not widely available to people. Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This unannounced key inspection took place between 10.00am – 5.00pm on the 8th August and 10.00am –12.30pm on the 9th August 2006. The purpose of the visit was to monitor standards of care in the home for people receiving a respite service and to look at progress in meeting the requirements and recommendations made at the last visit. A pre inspection questionnaire was sent to the home and was completed by the manager. The information from this questionnaire has been used in the preparation of this report. During the inspection I spoke to all of the service users and staff on duty, I looked at records and made a tour of the building. Before, during and after the inspection visit I conducted a telephone survey with six relatives; information from this survey can be found throughout this report. The manager was on leave at the time of this visit so feedback was given to two care officers. I would like to extend my thanks to everyone who contributed to the inspection and for the hospitality during the visit. What the service does well: The home strives to meet the requirements and recommendations made at inspection visits. During the feedback session the two care officers on duty were already planning how they could meet the requirements and recommendations from this visit. During this visit staff were enthusiastic, motivated and very knowledgeable about the needs of individual service users. This was a view echoed by one relative, who when surveyed said, “On my first visit to the home I was impressed by the manager and staff who were helpful and knowledgeable.” There is a good level of communication between staff, service users and their relatives. Two relatives surveyed spoke about good communication and one Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 6 person said that staff had visited her at home to discuss the service user’s needs. There is now a good level of training in the home, which is based around the needs of service users and staff have a good understanding of the diverse and cultural needs of people. The home tries very hard to make the respite stay as enjoyable as possible for service users. Comments from relatives surveyed included, “My son absolutely adores it, when he comes home he starts counting down for his next stay”, “My daughter is very happy, the home keeps her occupied. She gets excited when it gets near to her next stay”, “My relative gets so excited about going to the home, I try not to tell him in advance because he will pack his suitcase and be ready to go”. What has improved since the last inspection? What they could do better: Requirements that are outstanding from the last inspection are those that the organisation rather than the home must meet. These include erecting a boundary fence, providing written information about the home and what it provides and providing a contract of terms and conditions so that people know the rights and responsibilities of all concerned. These must be developed without further delay otherwise the overall quality rating of the home will be affected. Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 7 There must be some system in place that allows service users to call for assistance wherever they are in the home, and also for staff to summon assistance. To make sure that the home can meet the needs of new service users the manager or his representative should be an active member of the central allocations panel. Although relatives and service users said that they would complain if necessary not everyone could remember having a leaflet explaining how to complain. The complaints procedure must be made available to service users and relatives. To protect the rights of service users, restrictions must only be made on an individual basis and managed through a risk assessment process. The home must contact the infection control nurse for professional advice on how best to manage hand washing in service users’ bedrooms where liquid soap and disposable towels are not suitable. To stop the spread of infection clinical waste bins must be controlled by a foot pedal. The home must make some changes to the way that frozen food is stored to ensure food safety. Staff should contact the community dietician for advice on menu planning. The manager must make sure that records that are required for inspection are available at all times. To guarantee that the needs of all service users are met the organisation must provide training on cultural awareness and diversity and the manager should make cultural awareness an agenda item at staff meetings and in staff supervision sessions. Requirements and recommendations have been made to address these issues. 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. Raynel Drive DS0000033820.V303206.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 Raynel Drive DS0000033820.V303206.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, 4, & 5. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The rights and responsibilities of all concerned are unclear because there is no statement of purpose, service user guide and contract of terms and conditions. EVIDENCE: The service user guide and contract of terms and conditions are all still in draft form. These are outstanding from previous inspections and must be produced without further delay. All of the relatives surveyed said they had no written information about the home. One person expressed concern about night staffing levels. These concerns proved unfounded, but could have been allayed during the pre admission visit had the service user guide been available. Following an assessment of need, referrals for respite care are made to a central allocations panel; the manager of the home is not a member of this panel. This means that a pre-admission visit could be arranged before the manager has agreed that the home can meet the person’s needs. A recommendation has been made to address this. All of the relatives surveyed said they were able to visit the home before any decisions about accepting respite care were made. One person said that on her initial visit to the home she thought it was small, but had little choice because of the lack of respite provision in Leeds. Another person said that she Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 10 was happy that the home was small because she felt the service user would ‘fit in better’ in that sort of environment. To make sure that there have been no changes affecting the service user since their last visit to the home, staff make contact with relatives before the start of each person’s respite stay. This is good practice. Raynel Drive DS0000033820.V303206.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Care plans have improved and from the manager’s regular audit there is potential for them to improve and develop further. Service users are encouraged to make decisions and take risks, but for safety this is managed through a risk assessment process. EVIDENCE: The home is currently introducing a new style care plan that is written in the first person incorporating pictures and symbols. From the care plans sampled it was clear that the level of detail recorded has improved and overall there is good information for staff about the level of support each service user needs. Some plans needed more information, but this had been addressed because the manager has started to audit care plans on a regular basis. It is recommended that when care plans are audited a target completion date be given. Not all of the care plans sampled had a photograph of the service user and not all were signed by the service user and/or their relative. Daily records are limited and do not give a true reflection of how the service user has spent their day. A Requirement and recommendations have been made to address these issues. Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 12 Service users said that they could choose what time they went to bed and whether or not they joined in any activities. Staff explained about other decisions service users make such as choosing what clothes to wear and what to eat. Staff explained about the risks that service users take, and said that these are always managed through a risk assessment process. Risk assessments were seen for issues such as road safety, burns and scalds and physical harm from sharp implements when in the kitchen, having a bath unsupervised and wearing adapted footwear. Some risk assessments were completed when the service user was admitted and had not been reviewed since. A requirement has been made to address this. Raynel Drive DS0000033820.V303206.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are encouraged to keep to their normal daily routines and are supported to make use of local facilities. Recreation and leisure is seen as important and staff make every effort to make sure service users enjoy their stay. Some work is needed to make sure people’s rights are only restricted if there is a need and a risk assessment is in place. EVIDENCE: Service users take part in a variety of activities during their respite stay. Three relatives surveyed gave examples of how service users enjoy and look forward to their respite stays. One person said that her daughter is kept occupied at the home and from evidence in care records it is clear that service users make full use of the local facilities, such as shops, parks and leisure centres. One service user said that she liked the home because of the outings and described going to the funfair, bowling and walks in the park. Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 14 Service users continue their weekly routines. During part of this inspection some people were at day centres and staff provided transport so that one person could continue with his part-time job. The routines in the home promote independence wherever possible. Where service users have the ability they are encouraged to join in domestic activities such watering the garden, setting the table and helping to prepare simple meals. However, staff should make sure that service users are willing to undertake such activities and their agreement should be recorded in their care plan and should be reviewed at the start of each respite stay. From observation and discussions with staff and service users it was clear that service users’ rights are respected, but there are times when some rights are restricted because of the needs of other people. For example, bedside lights are not appropriate for some service users, so none are provided in any of the bedrooms. Because some service users may lose their key, all of the service users who have a key to their bedroom have to hand the key to staff when leaving the building. Where there is a need to restrict service user’s rights, this must only be done through a risk assessment process on an individual basis. During the feedback session staff were looking at ways to address these issues and were planning to review and evaluate all practices in the home. Service users are encouraged to plan the menu for the duration of their stay and then take an active part in the supermarket shopping trip. Service users described the meals as being ‘good’ and said that they can help themselves to snacks, such as yoghurts or biscuits, from the kitchen. Some unhealthy options were seen on menu records, but staff explained how they try to provide a balance by offering low fat chips, and burgers. One service user was glucose intolerant and another was lactose intolerant, in both cases comprehensive diet sheets were in place giving staff clear instructions on what the service user could and could not eat. Staff have had no training on food hygiene or menu planning and records did not always show that service users had a sufficient daily intake of fruit and vegetables. Staff said that they had not considered offering fruit smoothies or home made vegetable soups. The home should access the community dietician for advice on menu planning and should refer to the range of information now available to homes about nutrition. Requirements and recommendations have been made to address these issues. Raynel Drive DS0000033820.V303206.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are given support according to choices based on likes, dislikes and cultural beliefs. The manager is addressing weaknesses in the medication system. EVIDENCE: There have been three incidents involving service users being given the wrong dose of medication. The manager notified the Commission for Social Care Inspection (CSCI) about all three and took appropriate action. During the telephone survey, one person confirmed that she was aware of the medication error relating to her daughter. All staff who administer medication have now completed a distance learning package on medication, and a new system of checking service user’s medication before their respite stay has been introduced. Records were seen of staff making contact with relatives to tell them that the home cannot accept medication unless it has a pharmacist’s label bearing the person’s name, the dose, and the name of the medication. The manager has also placed administration of medication on the agenda for the next team meeting. Staff explained how medication is handled on admission and discharge, and is stored and administered properly. There were no errors found on the medication administration records. The person in charge of the shift holds the keys to the Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 16 medication cabinet, but these are attached to a larger bunch of keys for use in the home. This does not guarantee the safety of the medication keys and a requirement has been made to address this. Before this visit, the manager supplied the CSCI with home’s medication policy, along with other documents. The medication policy and procedure needs amending to state that the CSCI must be informed of any medication errors and the homely remedy policy needs to be more specific. For example the type of painkillers i.e. Aspirin, the maximum dose over a 24-hour period and the time limit for using homely remedies should all be specified. A recommendation has been made to address this. Service users are supported in a way that respects their independence, culture and choice. One relative surveyed said that because of cultural beliefs it is important that a female member of staff assists her daughter with personal care. As a result staff contact her before the respite stay to discuss staffing arrangements and if there are any gender issues her daughter’s stay is rearranged. One service user had a good care plan that gave staff detailed instructions on the precise amount of support he needed. For example, he preferred a wet shave; he could apply shaving foam and wash it off, but needed support with the actual shave. Staff gave other examples of service users preferring a shower rather than a bath, some because of cultural beliefs others because of personal choice. Although health care needs are monitored, little contact is made with the service user’s GP, or other health care professionals unless the service user is ill during their stay. One relative surveyed said that her son had become ill during one respite stay. The home took appropriate action and notified her immediately. They also offered to extend his respite stay until he was fully recovered and fit to return home. Raynel Drive DS0000033820.V303206.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Measures are in place to ensure that residents are safe and protected from abuse, but information about how to make a complaint is not widely available. EVIDENCE: Since the last inspection the CSCI has received one complaint about the home, which was passed to the manager to investigate. This complaint was dealt with properly. The manager carried out a thorough investigation, and responded appropriately to the complainant. There is a complaints procedure for service users and relatives to use, but the lack of a service user guide means that the complaints procedure is not widely publicised in the home. From the responses to the telephone survey some relatives remembered having had a leaflet on how to complaint, whilst others did not. A requirement has been made to address this. All relatives said that if necessary they would have no hesitation in making a complaint, and during conversations with service users it was clear that they would complain to their key worker. At the end of each respite stay service users complete a questionnaire, which gives them the opportunity to comment on any part of the respite break they were unhappy with. The responses showed that they are comfortable in expressing their opinions. All staff have completed training on adult abuse and when asked they were aware of the different types of abuse and of how to respond to any suspicion or allegation of abuse. Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Although there are some areas for improvement, overall the home is homely, comfortable and meets the needs of the service users. EVIDENCE: The home was tidy and smelt clean and fresh. The small family type home somewhat restricts communal and private space, but discussions are underway to move the laundry room to another area, which might create additional space. Furniture and fittings are those of a small home and service users seemed to enjoy stretching out on the spacious settees. Hand washbasins and a small safe for service user’s personal possessions have been fitted in all rooms. As stated earlier in this report, there were no bedside lights in bedrooms. Service user’s personal laundry is washed and ironed on the premises. When asked about any improvements in the home, one relative surveyed said that her son’s belongings are no longer misplaced and that when he returns home his suitcase “is nicely packed with clothes that are washed and ironed”. Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 19 The kitchen was very clean and tidy, and the fridge was well organised. There were some opened packets of food in the freezer, which were not secured and there was no record of when the packets were first opened. There is no emergency call system fitted in the home. Staff said that some service users would activate the system all night, but this is no justification for not installing one. Staff said that new gates are to be fitted at the same time as the boundary fence is erected. They are trying to make the outdoor area more attractive and have tended hanging baskets and fitted a bench seat in the entrance porch. They cannot however, be responsible for maintaining the large garden, with its lawns and hedges that at times look unkempt. Infection control is generally managed well, but staff were reminded of the need to use pedal operated clinical waste bins. There are no disposable towels or liquid soap in bedrooms; staff said that this is inappropriate for some service users. They were advised to contact the infection control nurse for professional advice on alternative methods of hand washing, such as the use of alcohol gel. A new member of the staff team had a good understanding of how to stop the spread of infection and was aware of when to wear protective clothing. Requirements have been made to address these issues. Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Recruitment appears robust, there is plenty of training on offer and staff are proactive in identifying training needs and finding resources to meet those needs. EVIDENCE: The manager was on holiday at the time of this inspection and staff on duty did not have access to any recruitment records. A new member of staff described a thorough recruitment process but this could not be checked. Records that are required for inspection must be made available at all times. A requirement has been made to address this issue. A care officer has recently agreed to take on delegated responsibilities for coordinating training in addition to her care role. Her enthusiasm was evident when she described how she had arranged for a community nurse to give an in-house training session on Epilepsy. Staff said that this was a useful training session that helped to build their confidence. Training on diabetes is planned to take place soon and other training being considered includes visual impairment, hearing impairment and other barriers to communication. Over the last 12 months staff have received training on adult abuse and adult protection and understanding disability. Staff who administer medication have all completed a Protocol distance learning pack on medication, and are to start another course on infection control. There is a commitment in the home Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 21 towards completing NVQ (National Vocational Qualifications) and one care officer said he was interested becoming an in-house assessor. A very new member of staff with no previous care experience described how she protects the privacy and dignity of service users and respects their rights and choices. She also had a good understanding of health & safety and fire procedures in the home. She said that she was starting a structured induction programme. Staff are aware of the diverse and cultural needs of service users. One person has developed a file to inform staff about different cultural, spiritual and religious needs. She said that she was thinking about asking different religious leaders to give informal training sessions to staff. This is to be applauded, but the organisation must take responsibility for this issue to make sure that all aspects of diversity, including people’s rights not to follow their religion or culture are respected. Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The staff team work well together and a good communication network benefits the service users and their relatives. EVIDENCE: It was clear from speaking to staff that the team are enthusiastic, motivated and constantly striving to improve standards in the home. During the feedback from this inspection staff were planning how they could meet some of the requirements and recommendations as a result of this visit. Staff said there has been a big improvement since the last inspection and that the team has now “gelled” and are working together. They said that the recruitment of another male to the staff team gives a good gender mix between staff and service users. Staff described a good level of support from the manager and said that there was good communication in the home, which in turn benefited service users. They also said that communication between staff and relatives had improved as a result of the new system of contacting Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 23 relatives before each person’s respite stay. During the inspection one relative phoned the home on the pretext of checking a respite date, but staff said they felt that the real reason for the phone call was, “the need for the person to ‘chat’ to someone with a listening ear.” Comments from relatives during the telephone survey included, “I have nothing but praise for the staff and the home” and “I am always made welcome when I visit the home”. Two relatives said that communication with the home was good, one person said that staff had visited her at home to discuss the service user’s needs, and others confirmed contact with staff before the start of each respite stay. After each respite stay service users are encouraged to complete a satisfaction questionnaire about their stay. From the responses it is clear that service users feel comfortable in expressing their opinions. Staff said that one service user had indicated that he did not like his respite stay in an all male group, as a result his next stay had been arranged with a mixed gender group. When reflecting on activities during his stay another person said he would like to see a ‘Bollywood’ movie; this had been arranged. There are times however, when situations are not easily resolved, particularly when the choices or opinions of service users conflict with those of their relatives. They said that differences about religion and culture between service users and relatives were difficult to deal with and the lack of policies and procedures specific to respite care did not help. These issues should be dealt with through cultural awareness training, staff meetings and supervision sessions. A requirement and recommendation has been made to address this issue. The manager completed a pre-inspection questionnaire, which showed that the required maintenance and service checks take place as required. The training co-ordinator and the manager are designated ‘fire marshals’, and are planning to start mandatory training for all staff on fire and evacuation procedures within the next two weeks. Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 24 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 1 2 2 3 X 4 3 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 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 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 2 X 3 X 3 X X 3 X Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 5 Timescale for action The home must provide a service 31/12/06 user guide. Previous timescales of 31.8.05 & 31/03/06 unmet. All service users must be issued with a contract specifying the arrangements made for respite care. Previous timescale of 31.8.05 unmet & 31/03/06 unmet. All care plans must have a photograph of the service user and must be signed by the service user and/or their representative. Risk assessments must be reviewed at the start of each respite stay. Service users’ rights must only be restricted through individual need and must be managed through a risk assessment process. The keys to the medicine cabinet must not be attached to other keys in general use in the home. Copies of the complaints procedure must be made DS0000033820.V303206.R01.S.doc Requirement 2. YA5 5 (3) 31/12/06 3. YA6 15 30/09/06 4. 5. YA9 YA16 13 12 31/10/06 31/10/06 6. 7. YA20 YA22 13 22 10/08/06 31/10/06 Raynel Drive Version 5.2 Page 26 8. YA24 23 available to relatives and anyone acting on behalf of a service user. A boundary fence or wall must be erected. This is unmet from 31.3.06. All food that has been opened and is stored in the freezer must be secured. A record must be kept of when the food was first opened. The home must consider fitting an emergency call system in all rooms. Clinical waste bins must be controlled by a foot pedal. 31/12/06 9. YA17 13 10/08/06 10. 11. YA24 YA30 12 13 31/12/06 31/10/06 12. 13. YA34 YA35 19 18 Advice must be sought from the infection control nurse about alternative methods of hand washing in bedrooms where liquid soap and disposable towels are not appropriate. Records required for inspection 10/08/06 must be made available at all times. The organisation must provide 31/12/06 training for staff on cultural awareness and diversity. 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 YA3 Good Practice Recommendations The home should be involved in the assessment process prior to admission; this includes a representative from the home being a member of the allocations panel. This is outstanding from 15.11.05. When care plans are audited a target completion date should be specified. DS0000033820.V303206.R01.S.doc Version 5.2 Page 27 2. YA6 Raynel Drive 3. 4. 5. 6. YA6 YA16 YA17 YA20 7. YA37 Daily records should give a true reflection of how the service user has spent their day. Where service users take part in domestic activities an agreement should be recorded in the care plan, which is then reviewed at the start of each respite stay. The home should access the community dietician for advice on menu planning and refer to the range of available information about nutrition in care homes. The medication policy should be amended to state that the CSCI must be informed of any medication errors. The homely remedy policy should specify the type of painkillers permitted, the maximum dose over a 24 hour period and the time limit for using homely remedies. The manager should address cultural awareness and diversity through supervision sessions and staff meetings. Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Raynel Drive DS0000033820.V303206.R01.S.doc Version 5.2 Page 29 - 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. 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