Inspection on 07/08/07 for Salingar House

This inspection was carried out on 7th August 2007.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Salingar House 10/08/06

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 Key Inspection 7th August 2007 10:30 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.V346522.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.V346522.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.V346522.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 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 flats 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 consist of a lounge, two dining rooms, and a rehabilitation kitchen and there is an outside area with seating. The garden is private. The weekly charge payable by people who use the service, to live in the home is between £61.35 and £90.65. Placing authorities from which people originate make supplements to the weekly fee. DS0000034546.V346522.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection of Salingar House has taken place over a period of time and involved sending a request for information to the home in March 2007 concerning people who use the service and their family members, as well as staff and details of the home’s policies, procedures and practices. We received the requested information a month later and questionnaires were then issued to people and their relatives, their GP and any other health care professional with an interest in their care, to social service departments commissioning their care and to the staff working in the home, in June 2007. The information obtained from surveys and that already known from having had contact with the home over the last few months, was used to suggest what it must be like living at Salingar House. A site visit was made to the home on 7th August 2007 to test these suggestions, and to interview people who use the service, staff, visitors and the home manager, if available. Some documents were viewed with permission from those people they concerned, and some records were also looked at. The communal areas of the home were viewed. Four people who use the service were spoken to and two care officers were interviewed. A senior care officer was also interviewed during the site visit to seek information, as the manager was unavailable. One relative was also spoken to on the telephone about the care in the home after requesting this via the survey. What was said was checked against the information obtained through questionnaires and details already known because of previous information gathering and contact with the home. Judgments were made using the information to say what it is like living in the home. What the service does well: People who use the service have their differing needs well assessed and checked to make sure they fit in with everyone else before they are admitted to the home, and to make sure their needs can be met. Some people have lived there a few years. People receive satisfactory information in written and picture format on what the home is like. People who use the service have good care plans and health plans made, that reflect their individual personal and differing needs, to show care officers what DS0000034546.V346522.R01.S.doc Version 5.2 Page 6 care they need. All plans are regularly reviewed. People have good support to maintain their physical, emotional and mental health and wellbeing, whatever their culture, race, religion, sexuality, disability etc. People enjoy making choices and decisions of their own and take risks in life if necessary, but only when risks are lessened. People enjoy good levels of activity, in the home or the community, and have developed good relationships with care officers and friends. Their rights to make decisions are well respected. The food given to people 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. People who use the service are given good support with their physical, emotional and personal needs, and with the taking of medicines. If they have a complaint, then care officers and management help then to put things right. If anyone harms or injures them, they can be sure whomever they tell will deal with issues effectively. People who use the service have a good environment to live in, are cared for by qualified care officers in sufficient numbers, and are protected by effective employment systems. They are also protected from harm by good practice and regular checks on safety within the home. What has improved since the last inspection? The service has made sure some senior care officers and care officers have undertaken refresher courses in some of the mandatory subjects required of care workers. The service has further developed the quality assurance system and produced an annual report. The service has marginally improved the protection of people who use it by having three care officers undertake safeguarding adults’ training. The service now has a full complement of cooking staff. DS0000034546.V346522.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. DS0000034546.V346522.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 DS0000034546.V346522.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 only. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Placing authorities and the home manager adequately assess peoples’ needs so they are confident they will be met. They receive sufficient written information from the service so they can decide if the home is the right place for them. EVIDENCE: Discussion with people who use the service, a senior care officer and care officers and viewing of documents reveal there are no changes from the arrangements to obtain assessment information from the placing authority, since the last inspection. Permission was obtained to look at one person’s case files. These contain evidence that the placing authority assessment document is obtained, used and held on file. Documents are updated as necessary and as needs change. The one seen had been reviewed and up dated in May 2006. There have been no significant changes to the assessment process and holding of evidence since the last inspection. Discussion was held about the home’s ‘statement of purpose’ and ‘service user guide.’ It is understood these documents have been in use for some time, but they have not been reviewed. Reviewing of them is therefore recommended. DS0000034546.V346522.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People have good care plans that enable them to be independent and to make choices, and people enjoy making their own decisions in life, with good risk assessments being put into place where necessary, so they are confident their lifestyles meet their expectations. EVIDENCE: Discussion with people who use the service, a senior care officer and care officers and viewing of one person’s case files reveals people have care plans that are used to help them achieve independence, take part in the local community and make decisions and take risks once risk is reduced. People who use the service speak about support being provided for their personal, social and emotional care, etc. in away that suits them and that meets their individual differing needs. They take each day at a time, live for DS0000034546.V346522.R01.S.doc Version 5.2 Page 11 the next event they have planned and enjoy a routine that suites them and is very much of their making. One person frequents many of the local church social events, satisfying both a religious and social need. People are aware of their care plans and programme documents. One care plan seen contains information on daily routines for hygiene and personal care, on dressing, use of the toilet, mobility, sleeping, eating and drinking, on medication taken, religion, interests and hobbies, and on any risks that may be evident because of these needs. It also contains a personal profile, a ‘communication passport,’ a ‘personal passport’ and a weekly activity plan. There is evidence of people making choices in diary notes and in the actions they take on a daily basis, as observed on the day of the site visit, in respect of going out, what to eat etc. All activity and choices made are recorded in diary notes. Care officers are also able to demonstrate how and when people make choices, in relating people’s routines and preferences. There is a culture amongst the care officers, which fully embraces the encouragement of people’s individual thoughts, feelings and rights and care officers are also proud of the people who use the service that have changed and developed over the years. Risk assessments play a key role in enabling people to undertake potentially risky activities, and lessen the risk where possible. Documents are available in files. Support is almost always necessary and is well provided. DS0000034546.V346522.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People lead and enjoy appropriate inclusive, healthy and fulfilling lifestyles in the home and within their local community, so their quality of life is good. EVIDENCE: Discussion with people who use the service, a senior care officer and care officers and viewing of one person’s case files reveals people lead lifestyles of their choosing. People have individual weekly activity plans, which show what they plan to do and where they plan to be. These include individual activities, and work placements and programmes. Included are college courses, employment, social events and outings, and such as visits to family etc. One person spoken DS0000034546.V346522.R01.S.doc Version 5.2 Page 13 to enjoys shopping most of all, had planned a trip to the local Bransholme Centre and was having lunch out as part of the activity. Several others were taking a tour in the home’s bus to Scarborough and incorporating lunch out as well. One person was waiting for art class in the afternoon and did not go out with the rest, but had already been out for a shopping spree. There are many individual comings and goings at Salingar House and people are always supported by care officers and senior care officers. People also experience opportunities to meet new people in the community as well as interact with their peers, because of this. Each person who uses the service determines their daily routine to suit their individual preferences. Set routines are mainly around meal times and being home in the house at a reasonably safe hour. Other than this people choose when to rise, one was still in bed during the first hour of the site visit, when to bathe and dress, what to wear, etc. People’s rights and responsibilities are respected and upheld. Most people have keys to their room and all receive their post unopened. Some people take responsibility for maintaining their room in a reasonable state and some also carry out household chores, especially if they choose to prepare their mid day meal or breakfast etc. There is a separate kitchen facility for this purpose. There is also a main kitchen, subject to environmental health standards and regulations, where an employed cook prepares lunch and the main meal of the day. All people’s preferences and likes are known and menus are compiled according to choices and healthy eating guidelines. There are no concerns from people regarding the provision of food. People made choices from the selection of lunch foods available and all ate very well, as we observed during the meal while taking the opportunity to get to know them. DS0000034546.V346522.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People who use the service receive good assistance and support to maintain their personal and health care, so they are confident their needs will be met. They do not experience the opportunity to self-medicate, because of risk, but their levels of choice and independence are good in all other areas. Medication systems are good in respect of storage and recording so service users needs are met safely. EVIDENCE: Discussion with people who use the service, a senior care officer and care officers, and viewing of health care plans and other documents reveals people have their personal and health care needs well recorded and well met. People have individual health care plans, which are compiled in conjunction with the senior care officers and the Community Team Leader Disability nurses. These include all aspects of personal and health needs and have action plans that show how needs are to be met etc. There are records of DS0000034546.V346522.R01.S.doc Version 5.2 Page 15 medication taken and any visits to or from health care professionals. Where possible all information is confidentially maintained and care officers only receive information on a need to know basis. Weight and other charts are maintained if they prove to be necessary for the continuing health of individuals. One file seen also has behaviour management guidelines, which are individually compiled and used according to individuals’ behaviour needs. People spoken to agree their health needs are met in a way that they prefer and request. Where problems arise the issues are discussed and solutions mutually found. Specialist services are accessed as necessary for particular health issues and support is provided to attend hospital appointments etc. Records are maintained of all visits made and assistance provided. People tend not to self-medicate, but have the care officers assist them, though some do have control of such as topical creams. No one self-medicates at the moment. Those spoken to are satisfied with the arrangements for medication administration. Systems for handling medication are good. There is a medication room with three metal storage cupboards and a fridge. There is a monitored storage system in use, a system for returning drugs, a control drug register, checks on and records of the room and fridge temperatures, and monthly reordering and stock control checks. There is also a list of the medications in use and their abbreviations, and a photograph of one person that visits regularly for respite care. The medication administration record sheets are well maintained and care officers also keep a record of any medication taken out of the home or retuned on a daily basis. There are regular pharmacy checks carried out and reported on, the last one being done on 22/02/07. There are no issues for the home to address. DS0000034546.V346522.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People who use the service are confident their concerns and complaints are listened to and acted on, and they are safeguarded against harm or injury, so service users are properly protected. EVIDENCE: Discussion with people who use the service, a senior care officer and care officers and viewing of documents and procedures reveals people have effective systems to use to make complaints or to pass on details of suspected abuse. People and relatives have opportunities to make concerns and complaints known, have made complaints and have had these satisfactorily dealt with in the past. The home has a complaint procedure on show, which is in picture format and Braille if required. The home also maintains a record of complaints received. There have been three complaints since the last inspection, all dealt with satisfactorily, one founded and two partially founded. The manager and care officers consider complaint handling is a healthy process to go through. People are encouraged to make complaints where justified and their rights to do so are upheld. There have been no problems with safeguarding adults’ issues in the last twelve months, no safeguarding adults’ referrals and no names referred to the DS0000034546.V346522.R01.S.doc Version 5.2 Page 17 government register of undesirable workers. At the last inspection senior care officers and care officers had not undertaken recent safeguarding adults’ training and a requirement was set for them to do so. The records of training available for this inspection and information provided on the pre-inspection questionnaire received in April 2007 show that three care officers have done the manager’s awareness course in response to the requirement. This effort must continue so that all care officers have up-to-date safeguarding adults’ training. We acknowledge that there has been a very recent major problem for Hull City Council Social Services Training Department in maintaining training courses due to flooding problems. We also acknowledge there are many opportunities and systems available within the council and other organisations and networks with which people are involved for them to make their concerns known. Care officers and senior care officers still need to undertake up-to-date safeguarding adults’ training to ensure people are well protected from abuse and harm. Other systems to promote and protect people’s safety and wellbeing, such as whistle blowing and following of policy, procedure and guidelines are not in question, as they are in place and are understood by care officers. People’s finances are protected from abuse by ensuring practice follows written council procedures and guidelines. Few people rely on their finances being looked after by the home, but most do have personal allowance held in safekeeping. Two people were asked about money held for them and both were satisfied they could access funds readily when they requested it. Records in place for handling finances were not inspected on this site visit. DS0000034546.V346522.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People who use the service enjoy a clean, comfortable and homely environment, in a home that is suited to it stated purpose. EVIDENCE: Discussion with people who use the service, a senior care officer and care officers and viewing of the communal areas of the home reveals that the premises is suitable for its stated purpose and that they are clean and comfortable. All communal and private areas are assessed for their suitability to meet the diverse needs of people, with regard to their physical and learning disabilities. People are very happy with their living environment and enjoy the private space they have. All rooms or flats are en-suite with either a bath or a shower DS0000034546.V346522.R01.S.doc Version 5.2 Page 19 and a toilet, and there are also three bathrooms and one shower available. A programme of routine maintenance is followed and all repairs are reported to the council for action. People have a choice of decoration in their rooms and furniture, fittings etc. are of a satisfactory standard, and that meet individual differing needs. The home meets the requirements of the local fire service and environmental health department, visits last being made in June 2005 and January 2004. There has also been a health & safety department inspection in April 2005. The laundry in the home is well maintained and meets the requirements of the Water Supply (Water Fittings) Regulations 1999. The home has wide corridors for wheelchair use if necessary, although people who use the service tend to be physically able. The home has good access to the local shops and a regular bus service is available to take people to the centre of Hull and beyond. Areas seen are clean, comfortable and hygienic. One person said, “I like living here, it’s really nice.” Another said, “My room is nice.” DS0000034546.V346522.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People who use the service benefit from appropriately recruited and well-trained staff in sufficient numbers to meet their needs, so they are confident their lifestyles will be respected. EVIDENCE: Discussion with people who use the service, a senior care officer and care officers and viewing of some documents reveals there are sufficient numbers of staff on duty, with the right qualifications and skills to do the job. We determined that there have been no changes to the recruitment and selection systems followed by the council since the last inspection, that there are now 93 of senior care officers and care officers with the recommended qualifications and that there are sufficient numbers of them on duty to meet the needs of people who use the service, as recommended by the Residential Staffing Forum. Newly recruited care officers undertake Learning Disability Award Framework induction and foundation training, which includes awareness DS0000034546.V346522.R01.S.doc Version 5.2 Page 21 of the equality and diversity issues within the caring profession, and equips them to understand and take into consideration, the diversities experienced by people who use services and people who work to provide them. The area of training and providing mandatory courses for care officers has seen a slight improvement in the numbers completing fire safety and infection control awareness. Since the last inspection 6 have done the fire safety and 5 have done the infection control training. This needs to continue so that all senior care officers and care officers have up-to-date training in these and other areas. DS0000034546.V346522.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People who use the service benefit from having a qualified and registered manager that is competent and is maintaining consistency within the service. They have a quality assurance system in use that is effective and they enjoy good protection from harm under the home’s health and safety measures in place and the practices carried out, so people are confident their health, safety and welfare are well promoted and protected. EVIDENCE: Discussion with a senior care officer and care officers, and viewing of some of the homes documentation and certification reveals the home is being well managed, satisfactorily maintained in respect of health and safety and the service of care is being monitored under the home’s quality assurance system. DS0000034546.V346522.R01.S.doc Version 5.2 Page 23 The manager is qualified and experienced to run the home. There is a quality assurance system, that has been in place for some years, and which now involves surveying other stakeholders as well as people who use the service. Evidence is available to show that members of the Community Learning Disability Team and people’s GPs were surveyed in April and May 2007. Information gathered from the complaints records, health and safety monitoring and checks, reviews of the care of people who use the service, people’s meetings, opinions on the provision of food, people’s surveys etc. has been collated to produce a quality assurance report for the last year. This is available for informing the home’s annual development plan. The quality assurance systems have not yet been reviewed under regulation 24, so if they are reviewed at any time a copy of the report on the review needs sending to us. Areas sampled for the purposes of assessing standard 42 are fire safety, gas and electrical safety, first aid training, accident recording and reporting. The legionella water certificate was verified at the last inspection. There is a newly written fire risk assessment document in line with new fire safety regulations, as identified by ‘ADT Fire’ on 05/07/07. The recommendations made were for there to be new signage on the fire doors, and for the break glass points to be numbered and put onto a cycle of testing, and recording. These recommendations have been carried out. There are weekly equipment checks on the system and monthly evacuation drills held, and both are recorded. The fire safety system was last maintained on 05/07/07, and the last Fire Prevention Officer visit was on 16/06/05. The gas systems were last checked on 18/07/06, and an electrical engineer maintenance check was last done on 05/07/07. Portable appliances were last checked in June 2007. First aid training was undertaken by two care officers over the last twelve months, but information from the senior care officer spoken to is that all senior care officers have completed the four day first aid training and all care officers have done the basic emergency aid at work course. Accidents are recorded on council forms that comply with the data protection act requirements. DS0000034546.V346522.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 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 3 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 3 34 3 35 3 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 3 X X 3 X DS0000034546.V346522.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 YA39 Regulation 24 Requirement The registered provider must ensure that a review of the quality assurance systems is undertaken, a copy of which to be forwarded to CSCI, so people are confident systems are used effectively to inform the service where improvements are needed. (Previous timescale 30/09/06 not met.) The registered provider must make arrangements by training staff, to prevent people being harmed or abused or placed at risk of being harmed or abused, so they are confident their safety and wellbeing is promoted and protected. (Previous timescale – 30/11/06 was only met in relation to three staff undertaking the training.) Timescale for action 31/10/07 2. YA23 12 and 13(6) 31/10/07 DS0000034546.V346522.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The registered provider should make sure the home’s ‘statement of purpose’ and ‘service user guide’ are reviewed and kept up-to-date, and new copies provided to people who use the service, so they know what the home’s intention is and prospective users of the service can decide if the home is the right place for them. The registered provider should make sure all staff completes regular mandatory training in the areas that affect them in their roles, so that people who use the service are confident they are being supported by competent and skilled staff. 2. YA35 DS0000034546.V346522.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI - 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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