Inspection on 10/08/06 for Salingar House

This inspection was carried out on 10th 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Salingar House 07/08/07

Salingar House 07/03/06

Salingar House 24/10/05

Salingar House 22/02/05

Salingar House 22/07/04

Salingar House 17/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Salingar House 2 Logan Close Midmere Avenue Kingston Upon Hull East Yorkshire HU7 4DG Lead Inspector Janet Lamb Unannounced Inspection 10th August 2006 09:30 DS0000034546.V307486.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 DS0000034546.V307486.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. DS0000034546.V307486.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Salingar House Address 2 Logan Close Midmere Avenue Kingston Upon Hull East Yorkshire HU7 4DG 01482 825778 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) Kingston upon Hull City Council Ms Catherine Spivey Care Home 11 Category(ies) of Learning disability (11) registration, with number of places DS0000034546.V307486.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: Salingar House is situated on the Bransholme estate in Hull. There are a variety of local community facilities close at hand and the service users go out on a regular basis. The home is close to a bus route. The home offers long term and respite care to a maximum of eleven people of either gender whose primary need is a learning disability. It is a Local Authority run home. The environment is warm and friendly and the care provided is based on individual need. The home consists of three self-contained flat lets and eight single bedrooms four of which have mini kitchens. Four of the bedrooms have en-suite bathrooms (with toilet and bath) and the other four have en-suite bathrooms (with toilet and shower), all meeting the minimum requirements regarding living space. The communal areas consisted of a lounge, two dining rooms, and a rehabilitation kitchen and there is an outside area with seating. The garden is private. DS0000034546.V307486.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began with the sending of a pre-inspection questionnaire to the home in late April 2006, requesting information on the service provided and the names of those service users living there, as well as the names and addresses of their relatives and any health care professionals involved in their care. Survey comment cards were then issued to as many of these people as possible, including service users, to obtain their views and opinions of the care provided within the service. Then on the 10th August 2006 Janet Lamb visited Salingar House, without prior warning and as part of this inspection. Several of the service users were spoken to and two were interviewed, but most of them were observed throughout the inspection. The Manager, one senior care officer and two care officers were interviewed, and another senior care officer and care officers were asked questions throughout the visit to obtain particular pieces of information. The main parts of the house were inspected, as were four service users’ bedrooms. Care plans, risk assessment documents and some records were read and staff files and training records were seen. All personal and private areas and documents were only seen with the permission of the people they belonged to. Janet Lamb had lunch in the dining room with six service users and three or four staff, and then spent some time talking to two service users and three staff in the garden. What the service does well: Service users are well assessed and checked to make sure they fit in with everyone else before they are admitted to the home, and other people living there are asked if they think they will get on with them. Some service users have lived there a few years and have learned to get on. One said, “All my friends are at work.” Service users have good care plans made to show staff what care they need, and these are reviewed regularly. Service users enjoy making choices and decisions of their own and take risks in life if necessary, but only when risks are lessened. DS0000034546.V307486.R01.S.doc Version 5.2 Page 6 All service users enjoy good levels of activity, in the home or the community, and have developed good relationships with the staff and friends. Their rights to make decisions are well respected. The food given to service users is good and they can either have it prepared by the cook or they can make their own meal in the rehab kitchen to help improve their independence and choice. Service users are given good support with their physical, emotional and personal needs, and with the taking of medicines. If they have a complaint, then staff and management help then to put things right. If anyone harms or injures them, they can be sure staff will seek justice. Service users have a good environment to live in, are cared for by qualified staff in just sufficient numbers, and are protected by effective employment of staff. They are also protected from harm by good practice and regular checks on safety within the home. What has improved since the last inspection? 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. DS0000034546.V307486.R01.S.doc Version 5.2 Page 7 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 DS0000034546.V307486.R01.S.doc Version 5.2 Page 8 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): 2 only. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are well assessed and their individual needs are being considered for compatibility with others in the home. EVIDENCE: Two new service users have been admitted to the home since the last inspection, and both were fully assessed by their placing social services departments, as well as the home. Assessment documents are held in their files. The Manager has devised a document, which records the consulting of existing service users about new service users possibly coming to live in the home. It considers compatibility and asks for existing service users’ views on whether or not they think they will ‘get on with’ the new service user. Measures are now in place to avoid any incompatibilities between those people using the service permanently and for respite care only. There is a marked improvement in the way service users are considered for permanent or respite care. Management of challenging behaviour has improved in the form of one to one care being funded and provided for, when necessary. DS0000034546.V307486.R01.S.doc Version 5.2 Page 9 Service users spoken to made no negative comments about the people they share the home with, and they were observed getting on quite well with one another. They were also accepting and tolerant of each other’s presence and needs. Some comments and actions suggested they have learned to ignore issues or behaviours that have in the past upset or annoyed them. One service user said, “I like living here, but I have no friends. My friends are at work.” The Manager confirmed that assessments are more stringent now and consider existing service users’ needs and preferences. DS0000034546.V307486.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users enjoy making their own decisions in life, with good risk assessments being put into place where necessary. Care plans are satisfactorily reviewed as requested or in line with the requirements of the providing authority. EVIDENCE: Although care plans are in place for service users, these had not been reviewed at the time of the last inspection. Information seen in service users’ case files shows reviews have been held over the last three months. The manager confirmed that all service users had gone through the review process since the last inspection. Service users are also the subject of a three monthly case discussion within the home and this always takes place before a review is held. Service users have, where possible, signed their care plans and review documents as a sign of their agreement to the action plans being implemented. Some service users were aware of their care plans and DS0000034546.V307486.R01.S.doc Version 5.2 Page 11 understood about the review process, indicating things had changed for them as a result of a review being held. Service users confirmed they make decisions within their daily lives, with or without support from staff and advocates, and acknowledged they do take risks. One relied quite heavily on the support of a key worker and answered, “I don’t know, ask my key worker,” to many of the questions she was asked. She also explained the key worker was one of the important people in her life and viewed her as a good friend. Other service users were observed interacting well with each other and especially staff. Service users displayed independence in such as preparing their own lunch, deciding when to take a bath or when to have a cigarette, or what to do during the day. One watched television for a short while then read books, another was occupied in her room with craftwork, supervised by staff, and another went out to work for the day. Two also went to the local shops to purchase goods, one independently and the other with assistance. All activities are now carried out with a written risk assessment in place and some of these documents were seen as part of the case tracking. The manager and staff confirmed the implementation of risk assessments. DS0000034546.V307486.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users lead satisfying lifestyles of their choosing, though some are given more support to do so than others. EVIDENCE: Service users spoken indicated they have a good level of autonomy and make daily choices, which affect their lives. They were observed making choices and seeking assistance where required. Some enjoy an element of rigid routine, which they set themselves, while others proved to be more flexible in their approach to life. Service users have individual activity programmes and some have work plans and routines. These were seen in case files. Service users make choices about the food they eat and the cook confirmed that they are asked about trying different meals and that she observes how they react to new foods etc. She explained she has a list of likes and dislikes but still offers new foods on occasion. DS0000034546.V307486.R01.S.doc Version 5.2 Page 13 Service users comments, made in ‘house meetings’ are recorded in minutes and in the home’s complaints/compliments file. Generally comments were about how much they had enjoyed their meal. One staff member explained service users make menu choices in meetings and make individual requests and decisions about their personal preferences, in one to one key working situations. The Manager explained that all but one service user has links with family and friends. Many of these people visit regularly and assist in some of the decision making for those service users less able to make their own choices. Diary notes showed evidence of family and friend links. Some service users spoke about family members, although one denied having any contact, which was corrected later by the Manager. Two service users now have part time jobs within the community. One had been to work on the day of the visit, but the other was on a day off. The arrangements for them to attend work are satisfactory and they enjoy the responsibility and especially the remuneration. One spoke of a sense of satisfaction saying, “I have a lot of friends at work. I like being there.” Staff consulted about the assistance given to service users reinforced the ethos that everyone is given the opportunity to develop to their potential. One criticism from staff was that about the repetition within care plan goal setting, and the poor acknowledgement of some service users’ achievements because of it. Other staff explained the use of the house meetings are a good way of consulting service users about their preferences, one saying “the only thing customers complain about really is the loss of the home’s minibus, which they lost some time ago, but still ask to have it returned.” DS0000034546.V307486.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users enjoy a good level of support with their health care and personal care, and with self-administration or administration of their medicines. EVIDENCE: All service users have ‘health action plans’ recorded within their care plans to show how health care needs are to be met and to record when and by whom a visit has been made. New service users now take part in a health screening process, which covers all areas of health need. Staff provide advice and support to service users on health related issues, and encourage them to be responsible for their safety and welfare. The manager and staff provided this information in interviews, and viewing service users’ care plans and case files, backed it up. Service users spoken to also confirmed they are given advice and information about health problems and helped to make decisions if necessary. One service user said, “if I am poorly I ring for the staff and they come to see me. Then they call the doctor for me.” Another service user complained of toothache while eating lunch and was encouraged to telephone the dentist to try to obtain an appointment. One service user was observed smoking, as were a DS0000034546.V307486.R01.S.doc Version 5.2 Page 15 couple of staff, while out in the courtyard together, after lunch. One staff explained that smoking by employees anywhere on Hull City Council premises is soon to be disallowed, under a change in council policy. The medication administration systems within the home were not fully met at the last inspection, but inspection of systems and records proved the discrepancies to have been corrected since then. Storage and safe handling of medicines is adequate, but could be good if the supplying pharmacist is asked to ensure that one more of the three required seals used on the Nomad monitored dosage system is put into place before delivering drugs to the home; it is recommended the seal to prevent the cassette from being opened be used. A telephone call to the supplying pharmacist was made within half an hour of pointing out the poor security on the cassettes. A message from him was relayed to the Inspector that he assured the main seal would be used, henceforth. Records of drug administration are good. The Manager queried the need to mark medication administration record (MAR) sheets with a nought when no “give as needed” medication is administered. It was decided that these drugs must be signed as given when given, and could be left blank when not, since there is no set or prescribed times for them to be given. All drugs of a set dosage and time to be taken must have nought entered on the MAR sheet when not taken or refused etc. (or another appropriately identified code must be used). Controlled drugs are maintained according to the requirements of the Medicines Act (1968) and guidelines from the Royal Pharmaceutical Society. They are double lock stored, and recorded and signed on administration, by two staff, in a controlled drugs register. The home follows good systems of returning unwanted or unused medicines, and obtains a signature for receipt of all returns from the pharmacist’s representative collector. Staff receive accredited training to administer medicines; ‘Approved Medication Administration Course for Adults,’ and ten have done so in the last 12 months, six since January 2006. The Manager has also done this training since January 2006. Some staff stated on questionnaires that they are still awaiting medication training, but it was evidenced that they were due to attend the course in May 2006 and for valid reasons did not. DS0000034546.V307486.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Although service users and relatives access effective and efficient complaint systems within the home, they cannot be guaranteed their safety from harm, neglect or abuse is protected, because only three staff have done vulnerable adults training. EVIDENCE: There are good systems in place and in use for making complaints and having these resolved satisfactorily, and for promoting the safety of service users and protecting them from abuse, neglect or self-harm. These systems are backed up by policies, procedures and guidelines for staff, relatives and service users to follow. The complaint procedure has been translated into picture form and also into Braille for those needing it, along with the home’s reviewed statement of purpose and service user guide. Staff receive training in protection of vulnerable adults issues, but the monthly record of training going back to December 2004 only shows three staff having completed this, and since November 2005. There is no record of the training having been done prior to this date. All four staff questionnaires returned to the CSCI indicate staff have an awareness of what the Protection Of Vulnerable Adults procedures are, but no one mentions having received training. The Manager stated there have been no vulnerable adult referrals in the home in the last twelve months. The Manager needs to provide more staff with the vulnerable adults training. DS0000034546.V307486.R01.S.doc Version 5.2 Page 17 Service users’ finances are protected from abuse by ensuring practice follows written council procedures and guidelines. Few service users rely on their finances being looked after by the home, but most do have personal allowance held in safekeeping. Two service users were asked about money held for them and both were satisfied they could access funds readily when they requested it. Checks were made on the balances and records held for two service users and both were accurate and well maintained. Staff are aware of and fully understand the council’s complaint procedures, and uphold service users’ rights to make complaints if they so wish. According to the complaint records held there have been three in the last twelve months and only one of these has been since the last inspection. Outcomes have been satisfactory and an action plan has been devised to address the issues of the last complaint as requested in the written requirement at the last inspection. Service users and relatives spoken to said they know who to talk to if they are unhappy about any part of the service. One relative recalled she and several other relatives had complained some time ago. The issues were discussed and action was taken to satisfy all of the complainants and to ensure the service users in the home were being cared for in a safe environment. She said there was little cause for complaint these days. Another relative felt sure he would be contacted and informed of any problem before it escalated to become the cause of a complaint. Two service users acknowledged their key worker was the best person to see if they had any worries or concerns. Standard 22 has been met on this occasion, but standard 23 has not. A requirement has been made for all staff to receive training in the protection of vulnerable adults awareness and reporting. DS0000034546.V307486.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 and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users enjoy a good level of cleanliness and hygiene within the home and the fabric of the building is well maintained. EVIDENCE: A tour of the building, looking at two bedrooms and two flats and all communal areas, revealed that personal space is highly personalised, spacious and comfortable, with all furniture and fittings as listed in standard 26 being in place. Flat 4 mentioned in the last inspection report now has reflective screening fitted to the glass to enable the service user to look out but prevent people looking in. The service user still insists on removing curtains and the rail from the wall. The recommendation to replace dining furniture at the last inspection has been considered for action and approved, but the council requires some quotes before the furniture will be purchased. This remains a recommendation. Another requirement at the last inspection was to eradicate offensive odours from the home. There were no problems with this on the day of the visit. The home was clean and comfortable and everywhere was pleasant. DS0000034546.V307486.R01.S.doc Version 5.2 Page 19 Service users made good use of their rooms throughout the day, coming and going as they pleased. One service user, interviewed in her room, said, “I have a very nice room, I like living here. I don’t use my kitchen, but I keep drinks in my fridge. I don’t like cleaning up.” Two recently received regulation 26 reports for June and July 2006 show the home carries out monthly checks on the fabric of the building and maintains a record of minor repairs needing to be done. These are cancelled out once the work has been done, but some repairs have been reported to the council and are still awaiting attention. The system works well. Interviews with staff revealed they are vigilant with regard to the condition of the home, and cleaners, working a maximum of 56 hours a week, appear to be doing a good job. DS0000034546.V307486.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, 33, 34 and 35. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit form good recruitment and selection of care staff, but not from a well-trained staff group in respect of mandatory fire safety and infection control training. Service users do benefit from 70 of care staff holding the appropriate NVQ qualifications. EVIDENCE: Information received from the manager and staff and viewing staff files, shows recruitment and selection procedures are well maintained and accurately followed. Three staff files were seen and all records held conform to the requirements of schedule 2, although two flies did not contain copies of references or the job application form. This is because the staff have been working for the council for some years and these documents are still held at headquarters. Details of Criminal Records Bureau checks are also held on files, along with contracts, job descriptions, induction records, sickness, holiday and supervision records. Where the home could improve in the standard on recruitment is to involve service users in the selection of new staff and to show how service users are DS0000034546.V307486.R01.S.doc Version 5.2 Page 21 supported through the processes of joining and departure of staff, including the review of staff at the end of their probationary period. All staff have a copy of the council’s code of conduct, which is kept within their files. Efforts have been made to improve the opportunities for staff training and the take-up of courses since the last inspection, but there are still shortfalls with fire safety awareness and infection control training. Evidence was seen, on the monthly training record and in letters to staff, that they have been provided with fire safety training courses, but many of the dates clashed with other courses and therefore staff did not attend. There are no details concerning infection control training, and therefore both remain as requirements following this inspection. Staff confirmed in interview and on questionnaires that training opportunities have been frustratingly thwarted. The obtaining of NVQ’s has been a more successful story. The interview with the Manager revealed two more staff have completed NVQ since the PIQ was filled out, consolidating the 70 of care staff now with the qualification. Some certificates were seen in staff files, and staff also confirmed their efforts with qualifications in interview. The home has also implemented the recommendation made at the last inspection concerning increased staffing levels for respite service users with challenging behaviour, and one service user was observed benefiting from this on the day of the visit. Interviews with staff and the Manager revealed all service users have experienced an improvement in their quality of life because of this. Staff did express a different concern though regarding the changing of staff responsibilities and accountabilities. The home used to be able to draw on senior staff from a council casual list at times when cover was needed. This list of people has diminished now, many having taken permanent jobs, and therefore care officers are being asked to interview for a benchmark and to lead shifts when senior care officers are on holiday or sick leave and cover amongst the other seniors cannot be found. The care officer leading the shift has the Manager available to call upon. Some staff do not feel they have full confidence in this way of working. Sometimes situations arise where the care officer leading the shift is not as experienced at handling them as the other staff on duty. This way of working needs to be reconsidered in light of the fact that the statement of purpose does not identify a ‘shift leader’ role in the organisational structure of the home. The Residential Staffing Forum was consulted about the care hours required for service users in the home at the time of the completion of the pre-inspection questionnaire: 1 high, 7 medium and 1 low dependency service users, and the outcome showed that the home is providing enough care hours per week to DS0000034546.V307486.R01.S.doc Version 5.2 Page 22 maintain basic cover, but not quite enough to ensure overhead hours are available. The care staffing hours are satisfactory as a minimum level of care cover. The Manager should make sure there is an effective contingency plan in place for covering a staffing shortfall below the minimum hours provided, in the event of an emergency. It was also noted that there is a vacancy for a cook within the home. This should be filled as soon as possible in order to meet the requirements of standard 33.2iii. A requirement is being made following this inspection. DS0000034546.V307486.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from having a qualified and registered Manager in the home that maintains a consistent service. They are provided with a good in-house indication of whether or not the service is good by means of the quality assurance system. They also enjoy protection from harm under the home’s health and safety measures in place and the practices carried out to maintain service users’ and staff health, safety and welfare. EVIDENCE: The Registered Manager in post at the last two inspections continues to manage the home. She is now fully qualified, having completed the NVQ Level 4 Registered Manager’s Award and has years of experience. She knows service users very well. The quality assurance system in place continues to be used to determine the quality of care being provided, but the system has still not been reviewed nor a DS0000034546.V307486.R01.S.doc Version 5.2 Page 24 report written in respect of this review, as required under regulation 24. A requirement was made at the last inspection for the review to be documented in a report, which has not been met and therefore remains a requirement following this inspection. The Manager has collated quality assurance information gathered and the levels of performance have been calculated to show percentage improvements, but this is not a review report of the systems in use. This information was seen, but the actual evidence on how the information was gathered was not. Service users were not interviewed about the quality assurance system, but staff were asked about the ways in which the home consults service users about the care they receive. Reviews, house meetings, and daily conversations are the most common ways of consulting service users. The quality assurance system is only periodically used. Evidence gathered in respect of standard 42 shows the Manager and staff follow health and safety regulations. The home had a “legionella” test done on the water storage tank in February 2004 and 2006. The certificates were seen. The Manager provides the staff with training in moving and handling techniques, as she is a qualified moving and handling trainer. Very few service users actually require assistance with their mobility and those that do only require assistance in or out of the bath for example, but nothing that warrants the use of lifting aids. Staff confirmed their training in moving and handling and the monthly training record shows 8 have received refresher training in the last 14 months. An interview with one staff member revealed personal protective equipment (PPE) is provided and used when service users require assistance of a very personal nature or when they are ill. ‘ADT Fire Safety Systems’ maintain all fire detection systems and equipment within the home and staff undertake weekly equipment checks and carry out monthly fire drills, all of which are recorded. There is a written fire risk assessment in place. The Manager confirmed fire safety checks are carried out and one staff member instructed the Inspector on where to exit the building should the fire alarms sound, on arrival at the home. All health and safety systems in place within the home are based on clear policies, procedures and guidelines available to staff. DS0000034546.V307486.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X DS0000034546.V307486.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA35 Regulation 17 and 18 Requirement The registered provider must ensure that all staff receive mandatory training including fire safety (annually), and infection control. (Previous timescale not met – 07/06/06.) The registered provider must ensure that the quality assurance system is maintained, an annual report is produced and shared with the residents, and a review of systems is undertaken, a copy of which to be forwarded to CSCI. (Previous timescales not met - 31/05/05 and 07/06/06.) The registered provider must make arrangements by training staff, to prevent service users being harmed, abused or placed at risk of being harmed or abused. The registered provider must fill the vacant cooks position to ensure the effective and efficient day to day running of the home, and to ensure that at all times persons are working in the home in such numbers as are appropriate for the health and welfare of service users. DS0000034546.V307486.R01.S.doc Timescale for action 30/11/06 2. YA39 24 30/09/06 3. YA23 12 and 13(6) 30/11/06 4. YA33 18 and 19 30/11/06 Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA24 YA33 Good Practice Recommendations The dining room table and chairs require replacement. The registered provider should make sure there is a contingency plan in place for covering a staffing shortfall below the minimum hours provided, in the event of an emergency. The registered provider should maintain evidence of staff recruitment checks within the home as listed in schedule 2. Some documents for some staff are only held at headquarters. 3. YA34 DS0000034546.V307486.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000034546.V307486.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. 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