Inspection on 29/06/05 for Safe Harbour Care Home

This inspection was carried out on 29th June 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Safe Harbour Care Home 24/04/07

Safe Harbour Care Home 28/02/06

Safe Harbour Care Home 07/12/04

Safe Harbour Care Home 06/04/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Safeharbour Care Home 254 Hagley Road Stourbridge West Midlands DY9 ORW Lead Inspector Jayne Fisher Announced 29 June 2005 th 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 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 Stationary 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. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Safeharbour Care Home Address 254 Hagley Road Stourbridge West Midlands DY9 ORW 01562 888125 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Safeharbour Juliet Prodger Care Home 7 Category(ies) of Learning disability (7) registration, with number (One service user may be aged 17 years) of places Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th December 2004 Brief Description of the Service: 254 Hagley Road, known as Safe Harbour, is a large detached building recently converted to provide accommodation for seven younger adults with a learning disability. The Home was Registered on 4 August 2003. It is situated in a residential area, on a main road in the Pedmore district of Dudley borough, with good access to community facilities and public transport. The building is set back from the road with off road parking for several vehicles and an enclosed area to the side of the property and level rear garden. The facilities include seven single bedrooms, well in excess of the minimum space requirements, all with wash hand basins. The services and facilities were set up with specific service users in mind and as a result of risk assessments carried out many weeks prior to each individuals admission to the home, there are currently no en suite facilities. Each room contains the pipe work and space to install en suite facilities should any service user be reassessed as being able to safely make use of such facilities in the future. There are adequate toilet and bathing facilities provided throughout. Individual bedrooms have been personalised with service users own belongings and with décor and furnishings of their choice. In addition there are three communal rooms, one with a television and two without. The Home was set up from the starting point of the needs of the service users who were known to be moving into the home, the service and facilities were developed to meet those needs. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted between the hours of 9.30 a.m. and 5.30 p.m. The purpose of the inspection was to assess progress towards meeting the national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: formal interviews with the manager, deputy manager, owner’s representative and six members of staff. There was also a tour of the premises. Bedrooms were not seen as residents were not available to give their permission. There are six residents currently living at Safeharbour. The home is registered to provide care for young people with learning disabilities and autistic spectrum disorders and other complex needs. All residents were involved in various community activities during the inspection. However the inspector was able to meet with two residents who were at home for a short period. Formal interviews were not possible therefore the inspector relied upon body language and observations of interactions between staff and residents. A number of records and documents were examined. Other information was gathered prior to the inspection which included the pre-inspection questionnaire, feedback from two relatives, one general practitioner, two community learning disability nurses, a speech and language therapist, a psychiatrist and two members of the psychology support team. What the service does well: The home is run by a professional enthusiastic management and staff team. When asked what the benefits were for residents living at Safeharbour staff responded by saying “they are treated like a family”, “it’s like a house not a care home; they are not treated differently because of autism”, and “we take them to different places, they have better social lives than me”. These statements were reflected in care practices during the inspection with a clear emphasis on residents expressing their own personalities and encouraged to make choices and decisions regarding their daily lives. For example, one resident had chosen not to go to college and staff therefore offered alternative options. Staff support residents to enjoy a wide range of community based and in-house activities which are geared towards their own wishes and needs. Residents can choose what they want to eat and staff make efforts to help residents to make their preferences known through different methods. Residents are able to go shopping and become involved in food preparation for example by watching staff prepare their meals. Staff eat their meals with residents which helps promote a congenial and friendly atmosphere. There is a comprehensive care planning system which assists staff and supports service users. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 6 There is a strong emphasis on staff training and support. The premises are attractively furnished which promotes a homely environment. Communal areas are bright with modern furnishings and decorated to a high standard. There were lots of positive interaction observed between staff and residents. For example one resident was seen watering the garden and teasing staff with a water hose with lots of laughter and smiles all round. All responses from relatives and professionals were positive, praising staff for the service provided. Some comments included “I feel Safeharbour go out of their way to meet the needs of each individual client”. “We are very happy we have been able to find such a safe and caring home”. “I have been impressed with staff’s approach to support the needs of my client, they have demonstrated a person centred approach which is reflected in their excellent rapport”. “My client has been enabled to make considerable development in their well being and quality of life”. “Safeharbour exudes a friendly and welcoming atmosphere at all times”. “The management and staff team are totally committed and dedicated to providing the best possible care. It is a real pleasure to work with the team whose example of providing support for life and not life support is refreshing and exciting within the area of learning disabilities and the development of adult care services”. What has improved since the last inspection? More efforts have been made in providing residents with information in formats they can understand. For example in picture, pictorial and photograph forms. Staff have worked hard with speech and language therapists to establish excellent communication books together with residents. There is a notice board with photographs of staff who are on duty, and the residents with whom they will be working during each parts of the day. This is particularly helpful as the home has a large staff team and residents can therefore be shown who will assisting them on a daily basis. The home has two activity co-ordinators who have drawn up new activity programmes for residents and these are also in pictorial format. There is lots of information available to inform new and existing residents about the services provided by the home. Improvements have been made with regard to undertaking appropriate checks before new staff commence work which safeguards residents from abuse. Improvements have also been made with regard to fire safety and infection control. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 and 5 The homes Statement of Purpose and Service User Guide are excellent providing service users and prospective service users with details of the services the home provides enabling an informed decision about admission to be made. EVIDENCE: Since the last inspection the home has amended the statement of purpose and service user guide so that all of the information required by the Care Homes Regulations 2001 is contained therein. These are comprehensive and well written documents. The home has also created new pictorial service user guides and upon these examination these are imaginative documents using photographs as well as pictorial symbols. The home has also devised a scrapbook containing information which can also be used as a service user guide. Since the last inspection the home has admitted a new service user. It was pleasing to see that the manager had written to the prospective service user confirming that Safeharbour could meet their needs. It was also impressive to see that a pictorial letter had also been sent. The home had not obtained a copy of the placing officer’s care plan and assessment. Management reported that they had had difficulties in trying to obtain this information. There was a comprehensive assessment of the new service user carried out during a number of visits by staff to the service user’s previous home and school. The service user also visited Safeharbour on at least four occasions. It was Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 10 pleasing to see that family were fully included. The majority of visits and assessments undertaken were fully recorded although not all, and it is recommended that all visits are recorded. There is ample evidence that Safeharbour can meet the assessed needs of service users. All specialist services are accessed, for example, speech and language therapy, psychology, psychiatry and behavioural support teams. Since the last inspection the Home has now introduced contracts/terms and conditions of occupancy which are held in individual case files. Only slight improvement is necessary for example, to include the exact fee charged and the specific room number occupied by the service user. The manager has signed the contracts and these should also be signed by the service user or advocate, if there are issues regarding capacity to consent. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 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 standard(s) 7 and 8 Staff respect service users’ rights to make decisions and strategies have been established in order to assist in decision making, thereby service users are supported to make choices and exercise control over their lives with assistance if necessary. EVIDENCE: Care plans were not fully evaluated at this inspection however they were examined as part of case tracking. The home is making good progress at introducing a person centred planning approach. As discussed different systems may be required such as essential life style planning. It was pleasing to see that elements of care plans had been reproduced in formats suitable for service users. With the help of speech and language therapists staff have assisted service users to establish communication passports. These are excellent documents and very useful aids in supporting service users with decision making. In addition a number of procedures have been translated into pictorial formats to assist service users. Some staff have also recently been on a ‘writing with symbols’ course which is an excellent initiative. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 12 Since the last inspection the home has contacted Dudley Advocacy service who have visited the home. Information is displayed in the foyer. It is not possible for individual advocates to be appointed for service users but they will become involved in specific projects upon request. Family generally act as appointees for managing service users’ finances. Although there are two exceptions where the Registered Manager and person nominated by the Registered Provider each act as appointee for two service users. The Care Homes Regulations 2001, 20(3) state that this should be avoided wherever practicable however, recent guidance published by the Commission for Social Care Inspection allows for flexibility in interpretation of these regulations as long as certain conditions are met. These service users’ monies are not held in a business bank account (at present the home is looking to establish bank accounts for the service users). It is recommended that records of service users’ financial transactions are independently audited on behalf of the Registered Provider as suggested by the guidance. It was pleasing to see that care plans contained goals with regard to assisting some service users to budget. Management also discussed that they are considering implementing a recognised qualification for service users towards independence. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 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 standard(s) 11, 12, 13, 14, 15 and 17 Links with the community are excellent which support and enrich service users’ social and educational opportunities. The meals in the home are very good offering both choice and variety and catering for special dietary needs of service users. EVIDENCE: Examination of documentation, interviews with staff and observations made through out the day confirms that Safeharbour supports service users to lead fulfilling lives outside as well as inside the home. The home has two activity co-ordinators who have recently devised pictorial weekly activity programmes. Staff complete comprehensive daily reports which are monitored by the activity co-ordinators who assist key workers to complete monthly report forms. They are also looking to devise their own monthly evaluation sheets. Activity programmes include independent living skills such as tidying bedrooms, helping with shopping and cooking and doing laundry. Service users attend schools and local colleges which is supplemented by the homes own day care provision. It was pleasing to note that staff are striving to find work placements for service users. Daily activities provided by the home include Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 14 community based activities, in-house activities such as music therapy, painting and arts and crafts. There is a strong emphasis on social inclusion which is commendable. Through out the day service users were going out on a variety of activities. Examination of a key worker monthly report on behalf of one service user revealed that activities had included visits to the cinema, safari park, zoo, Cannon Hill park, Bantock Park, Mere Road, Great Whitley, bowling, walking, Wasley Hills and various shopping trips. Staff strive to ensure good links are maintained with families. Management stated that as service users’ meetings would not be appropriate, they are looking to introduce a monthly key worker meeting with parents. The home promotes service users’ health and well being by ensuring nutritious, varied and balanced meals with an emphasis on healthy eating and freshly cooked meals. There is a two week menu plan. There are usually two or three choices for the main meal. The housekeeper explained that she usually cooks equal portions of each meal, service users are then able with assistance to make their own choices and staff (who eat their meals with residents which is excellent practice), then make their choices. It was pleasing to see that one service user who was at home for lunch was in the kitchen and assisted by staff to choose and make a lunch time meal. The food that was prepared looked appetizing and well balanced. It was pleasing to see that service users’ individual food preferences are catered for; the home is also devising a pictorial scrapbook to assist service users in making choices from the menu. There are also ‘taster’ sessions. Excellent records are maintained with regard to food choices made by service users. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 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 standard(s) No standards were assessed at this inspection. EVIDENCE: An assessment was undertaken to measure progress towards outstanding requirements in relation to medication. As required the home has now introduced a policy with regard to drug errors. Progress is being made with regard to providing all staff with accredited training in the safe handling of medication. Epilepsy training has been given to the majority of staff from the community learning disability nurse and specifically with regard to the administration of Stesolid. However new staff have been trained by the deputy manager (who is a qualified nurse) with the approval of the community learning disability nurse. As discussed, if the home wishes to undertake their own training in this area a written procedure and protocol must be devised which is ratified by the primary care team. The management agreed that further training will be accessed from the community learning disability nurse. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 There is a clear and effective complaints procedure thereby reassuring service users that their views are listened to and acted upon. EVIDENCE: There is evidence to demonstrate that the home investigates any complaints made in a fair and balanced manner and that all complaints are treated seriously. There is a complaints log and comprehensive policy. It was pleasing to see that the complaints procedure has been reproduced in a pictorial format. In addition to this there is a large pictorial poster displayed on the upstairs landing which is used by service users as a ‘quiet area’. This is an excellent initiative. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 27, 28, 29 and 30 The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: A tour of communal areas was undertaken. There is regular redecoration and maintenance of the premises. The home was exceptionally clean and tidy. The communal areas are bright and airy with comfortable and homely furnishings. Communal areas consist of two large lounge areas, a dining room and extra areas for dining and a large kitchen area. There is an attractive garden to the rear. The home has also a quiet area and well equipped snoezelen on the first floor. There are a number of bathrooms and a shower room situated on the ground and first floors. It was established that the shower on the first floor does not have a thermostatic stabilizer and therefore water temperatures can fluctuate and be adjusted. Only 2 residents use this facility. One with supervision and another without. Staff state that they both have an awareness of safety and water temperatures; a written risk assessment is therefore required. In addition bathrooms would benefit from storage space so that service users can store their clothing and personal belongings whilst bathing. Sensitive information regarding bathing could also be stored in these areas. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 18 Since the last inspection the home has made a number of improvements in respect of infection control. The laundry area is now improved with a wash hand basin fitted and flooring which has been made impermeable. All requirements made at the last inspection have been met. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 and 36 Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. The arrangements for induction of staff are good with staff demonstrating a clear understanding of their roles. EVIDENCE: The home employs 23 support staff, nine of whom are qualified to NVQ II or above. There are a number of staff who are currently undergoing this training. Specialist training is on-going. Some staff have been on training in managing challenging behaviour and breakaway techniques and management are actively trying to source more effective training. On examination of the duty rota the home is staffed appropriately to meet the needs of service users. For example there are six support staff on duty during the morning and eight staff in the afternoon. Staffing levels are high in order to meet the needs of residents, some of whom require either two or three staff during one to one sessions. There are regular staff meetings. Since the last inspection improvements have been made with regard to the recruitment and selection of staff. All pre-employment checks are undertaken and there is a rigorous and robust system of selection in place. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 20 A recommendation was made with regard to ensuring the names of former employers are included on the application form. The home uses agency staff to supplement shortfalls in the duty rota. There was evidence supplied from the agency that these staff have been appropriately checked in respect of criminal record bureau disclosure checks and protection of vulnerable adult (POVA) scheme checks. The manager had mislaid check forms for two of the agency staff on the current duty rota and contacted the agency during the inspection to ask for copies. It was suggested that the home liaises with the agency to ensure that these checks are undertaken at least annually as required by the POVA guidelines. There is a comprehensive training and development plan in place and staff also have individual training profiles. The home ensures that staff receive induction and foundation training which meets the requirements of the Sector Skills Council. There is on-going support for staff through structured supervision sessions. The home has yet to implement an annual appraisal system. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 41, 42 and 43 The manager is supported well by her senior staff in providing clear leadership through out the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: During interviews management demonstrated a clear vision for the home which has been effectively communicated to staff. Staff reported that they felt listened to by management and were able to ask for support from managers and their peers. Since the last inspection the home has now gathered all of the information required by the Care Homes Regulations 2001, 19(1)(b) regarding staff which is held in a well organised filing system. Health and safety was partially assessed at this inspection. Progress has been made with regard to outstanding requirements. For example, a written Legionella risk assessment has been undertaken as well as chlorination and bacterial analysis. There are regular checks of the water temperatures. There Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 22 are other improvements with regard to testing of the fire alarm system and The home has completed a control of substances hazardous to health. comprehensive food hazard analysis although some improvements are still necessary with regard to labelling of food products. Mandatory training is on-going and is a high priority with management. The home is making good progress in ensuring that all staff have received the required training. Some training certificates are still awaited as evidence that this training has been completed. Recent inspections have been undertaken by the fire safety officer and environmental health officer. There were no major issues identified. There are still some outstanding improvements necessary with regard to providing a business plan and reports from visits undertaken by the provider’s representative who although visits on a regular basis, does not complete a monthly report. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 3 2 2 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 2 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x 2 3 Standard No 11 12 13 14 15 16 17 3 3 4 3 3 x 3 Standard No 31 32 33 34 35 36 Score x 2 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Safeharbour Care Home Score x x x x Standard No 37 38 39 40 41 42 43 Score 3 3 x x 3 2 2 E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 24 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 2 Regulation 14(1)(b) Requirement Timescale for action 1/10/05 2. 5 5(1)(b) 3. 6 15 4. 20 13(2) To obtain a copy of the placing officer’s assessment and care plan prior to the admission of a new service user. To provide all service users with 1/10/05 a statement of conditions of residency to include all information contained within Standard 5.2 of the National Minimum Standards for Younger People. (Previous timescale of 1/9/04 is partly met). To demonstrate service user’s 1/10/05 (and family/advocate’s) participation in the development, review and agreement of their care plan – for example through person centred planning processes. Care plans to be reproduced in formats suitable for all service users. (Previous timescale of 1/9/04 is partly met). To provide accredited training for 1/10/05 all staff in the safe handling of medication. (Previous timescale of 1/5/04 is partly met). To provide training for staff in the monitored dosage system provided by the local pharmacy. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 25 (Previous timescale of 1/6/04 is partly met). To ensure that the names of staff who have been trained in the administration of Stesolid are included in the administration policy and procedure. To provide suitable storage in 1/8/05 communal bathrooms to enable service users to store their personal belongings and clothing whilst bathing. To pursue plans to fit thermostatic valve control to wash hand basin in bedroom no. 4 and to carry out a written risk assessment until this is installed. To carry out a written risk assessment with regard to shower on first floor which is not fitted with a thermostatic stabilizer in order to identify and undertake control measures to minimize risks of scalding. 1/10/05 To provide training for all staff in non-abusive psychological and physical intervention (NAPAPI) techniques which will assist in the management of extreme challenging behaviour. (Previous timescale of 1/6/04 is partly met). To ensure that 50 of care staff are qualified to NVQ II by 2005. To continue to pursue plans to provide all staff with awareness training in Autism Spectrum Disorder. To introduce an annual appraisal system for staff. To ensure that the Registered Manager has completed an NVQ IV in management by 2005. 5. 29 23(2)(l) 6. 32 18(1)(c) 7. 8. 36 37 18(2) 18(1)(c) 1/11/05 1/1/06 Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 26 9. 42 18(1)(c) To continue to pursue plans to ensure that all staff receive training in: 1) infection control (Previous timescale of 1/4/05 is partly met). 2) first aid awareness (Previous timescale of 1/4/05 is partly met). 3) health and safety (Previous timescale of 1/4/05 is partly met). To provide an up to date Landlord’s gas safety certificate for the annual testing of all gas appliances. (Previous timescale of 1/4/05 is not met). To make the following improvement to food hygiene practice: 1) To ensure that all high risk products are labelled with the date of opening. For example jars of salad dream. (Previous timescale of 1/4/05 is partly met). 2) To ensure that all products frozen by the Home are labelled with the date of freezing. (Previous timescale of 1/4/05 is partly met). To provide a business and financial plan for the Home. (Previous timescale of 1/9/04 is not met). To ensure that copies of reports of monthly visits undertaken in compliance with Regulation 26 are forwarded to the CSCI. (Previous timescale of 1/9/04 is not met). 10. 42 13(4)(c) 1/8/05 11. 42 16(2)(j) 1/8/05 12. 43 25, 26 1/9/05 Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 27 To ensure that the person nominated by the Registered Provider to undertake the monthly visits as in compliance with Regulation 26 provides a written report to the Registered Manager. (Previous timescale of 1/2/05 is not met). 13. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 4 7 34 Good Practice Recommendations To ensure that all introductory visits undertaken by new service users are recorded. To appoint an independent auditor to carry out audits of service users finances and records on a regular basis (at least annually). To expand the application form for new staff so that the names of former employers are ascertained. Safeharbour Care Home E55 S46649 Safe Harbour V22802 290605 Stg4.doc Version 1.40 Page 28 Commission for Social Care Inspection Mucklow Hill Office Park West Point,Mucklow Hill Halesowen B62 8DA 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. 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