Inspection on 11/12/06 for Saltshouse Road

This inspection was carried out on 11th December 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Saltshouse Road 27/02/09

Saltshouse Road 22/12/05

Saltshouse Road 07/07/05

Saltshouse Road 25/01/05

Saltshouse Road 12/08/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Saltshouse Road 199a 201a 203a Saltshouse Road Hull East Yorkshire HU8 9HG Lead Inspector Christina Bettison Unannounced Inspection 11th December 2006 09:30 DS0000000911.V323675.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 DS0000000911.V323675.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. DS0000000911.V323675.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Saltshouse Road Address 199a 201a 203a Saltshouse Road Hull East Yorkshire HU8 9HG 01482 618096 01482 329337 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) Avocet Trust Carol Ann Osbourne Care Home 8 Category(ies) of Learning disability (8) registration, with number of places DS0000000911.V323675.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd December 2005 Brief Description of the Service: The service at 199a-203a Saltshouse Road is managed by Avocet Trust who rent the premises from Sanctuary Housing. It is one of a small number of similar services that Avocet provides. Avocet Trust is a registered charity. 199a-203a Saltshouse Road consists of three separate units registered to provide care for 8 service users with a learning disability. The property is set back from the main road in the corner of a new residential estate, built in the old grounds of Tilworth Grange Hospital. 199a has three bedrooms one upstairs; all other accommodation is at ground floor level. 201a has two bedrooms and 203a has three. All bedrooms are singles four of which have ensuite facilities. Each unit has its own lounge, dining room, laundry room and shared bathroom. All units have their own front door and separate garden areas to the rear. The properties adjoin each other and share a large communal patio / garden at the front. Nearby there is a range of local shops, pubs, and health services. Public transport to various parts of the city is easily accessible and in addition some of the service users have leased their own cars; arranged through their mobility benefits. DS0000000911.V323675.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection (although the inspector informed the registered manager a few days before that she would be coming on this day to ensure that staff and service users would be in) and took place over 1 day in December 2006. Relatives’ surveys were posted out of which seven were returned; visiting professionals’ surveys of which three were returned, service users surveys of which five were returned and staff surveys of which eleven were returned. During the visit the inspector spoke to the registered manager, service users and staff. In addition observations of care practices and interactions were made. A relative commented, “We can’t thank the helpers enough how they look after …………. They are kindness itself and attend to her every need.” However another commented, “ Complaint was dealt with by home staff but very little response to it given by Avocet trust management and certainly not dealt with.” The inspector looked around the home and looked at some records. Information received by us since registration was considered in forming a judgement. Prior to the visit the inspector referred to notifications sent to the Commission for Social Care Inspection, the event history for the home since registration and the completed pre- inspection questionnaire. Weekly fees are £269.00 per person per week. Additional charges are made for the following: clothes, toiletries, newspapers/magazines, hairdressing, chiropody, transport for social activities and sweets. Information on the service is made available to current service users via the statement of purpose, service user guide and inspection report. The site visit was led by Regulation Inspector Mrs. C. Bettison and the visit lasted six hours. DS0000000911.V323675.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? DS0000000911.V323675.R01.S.doc Version 5.2 Page 7 Staff are up to date with all mandatory training which includes infection control, some service specific training has taken place and staff have completed training in how to protect vulnerable adults and how to manage difficult behaviour this leads to service users needs being met and them being protected from harm. New staff have either completed or are registered for induction that is for staff working with people with a learning disability. All staff have had an annual appraisal that identifies what training they need for the next year and they have regular recorded supervision. All of Avocets policies and procedures (rules) have been reviewed and amended to ensure that staff are aware of their responsibilities and are able to protect service users from harm. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. DS0000000911.V323675.R01.S.doc Version 5.2 Page 8 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. DS0000000911.V323675.R01.S.doc Version 5.2 Page 9 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 DS0000000911.V323675.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are being met by a staff team that are given full and proper information regarding service users living at the home to enable them to meet service users needs. EVIDENCE: Three care files were examined as part of the inspection. All contained the Local Authority community care assessment and care plan and all three service users had had a formal review of their care needs. There had been no new admissions to the home since the previous inspection. DS0000000911.V323675.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,and 9 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users have detailed individual plans that reflects their full range of needs; choices etc. ensuring that their complex needs will be met. EVIDENCE: All care records are in lever arch files and are presented in a tidy and organised way. There are good diary records to indicate what care has been delivered on a daily basis. The manager is routinely monitoring the care files and conducting audits to ensure that they meet requirements. Three care files were examined as part of this inspection. They included a very detailed pen picture that gave a very good initial overview of the service user, their history, needs, likes and dislikes. Service users individual plans were very detailed to ensure that staff are aware of service users needs and are able to provide appropriate and consistent care to meet their needs. In some places DS0000000911.V323675.R01.S.doc Version 5.2 Page 12 these had pictures to make them more accessible to the service users however it would be beneficial to further develop this. For one service user there was a very good outline prepared by the key worker of the service users presenting body language, explaining to staff what particular behaviours/facial expressions/noises mean and how they can tell if she is happy, sad, frightened or in pain. It was explained that this had been built up over time by staff who had got to know the service user well. This is an excellent piece of work and will help new staff to be able to communicate with her better and meet her needs. There was also a section in the plan for one service to have a regular colour put on her hair, this further demonstrates the staffs commitment to meeting service users diverse needs and wants and promotes dignity and respect and promotes a positive feeling of self worth for service users. All three service users had been reviewed by the LA and the homes own internal review mechanism and individual plans and been updated or amended following review. Reviews meetings included all family and relevant professionals and covered all of the pertinent issues. Where service users display behaviours that can be difficult to manage and specific techniques or methods of communication are required in order to minimise the risks behaviour management strategies are in place. These are well developed giving staff clear instruction on how to promote independence, meet needs and manage risks. There is robust monitoring and recording of any incidents and a vast range of risk assessments for any areas that pose a risk to service users. DS0000000911.V323675.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are assisted to continue their personal development and have access to the community for a wide range of leisure pursuits. Family contact is maintained and all service users enjoy a healthy diet. EVIDENCE: Service users social, emotional, communication and independence skills are developed and maintained by the use of detailed service user plans and risk management guidelines and risk assessment. Specialist staff from the community team learning disability offer specialist intervention and support. DS0000000911.V323675.R01.S.doc Version 5.2 Page 14 The inspector was informed that none of the service users are engaged in work placements however all of the service users engage in a wide range of activities to continue their opportunities for personal development. Activity timetables are produced in a symbolised version and a copy kept in the service users room to remind of them of their activities for the week. The inspector observed service users being offered choices as to whether they wished to attend activities or not. Service users participated in a range of leisure activities in the community and in the house e.g. spa bath and pampering, household chores, soft play sessions at the leisure centre, looking at photos/reminiscence, bowling and swimming, food and personal shopping, watching TV, community centre, Mencap walking group and visits to the pub. Contact with families is encouraged and maintained. Families are welcomed to visit and some service users visit their families at their homes. All relatives stated that staff kept them well informed of progress, problems and/or illness. On the whole service users had unrestricted access to the houses and gardens, where access was restricted due to safety reasons this was documented in the service users care file/ management plan. The manager and staff promote a healthy eating menu but try to balance this with service users likes/dislikes and special treats on occasions. Any restrictions are clearly documented in the care file and agreed to by the service user. DS0000000911.V323675.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of the service users are assessed, identified, clearly documented and are being met by the service, health colleagues and staff. The medication at the home is well managed promoting good health. EVIDENCE: Three service users care files were examined as part of the inspection process. There was evidence that contact with GP, dentist, optician, audiologist, chiropody, community nurses and therapists and consultants was being facilitated on a routine basis for service users. From observations it is apparent that staff promoted service users dignity, privacy and respect. Staff were observed to behave in an appropriate manner towards service users. DS0000000911.V323675.R01.S.doc Version 5.2 Page 16 Times for going to bed and getting up were flexible. Individual likes and dislikes were recorded on the service user plan and the communication passport. Health screening had been completed and records evidenced that access to dentist, optician, audiologist, chiropody, community nurses, consultants, specialist epilepsy nurse and therapists were being facilitated on a routine basis for all service users. There were nursing care plans and epilepsy management plans in place. For one service user there was evidence that routine tests for Anaemia, thyroid malfunction and a medication review had all been completed in this year. Best of interest meetings had been held for decision making where it was felt that the service user was unable to make an informed choice about health care or treatment. Continence, sleep and weight monitoring was in place and healthy eating diets promoted for those service users that needed it. The Community Team Learning Disability have been approached to assist in the preparation of Health Action plans to ensure that service users health needs are identified and services provided to meet these needs, however in the meantime the staff at the home have developed an excellent booklet for each service user entitled “Healthy me” which details everything staff need to know to ensure that the service users health needs are being met. Action plans are included within this booklet and there was evidence that staff are attending to areas identified on the action plan. The home has policies and procedures for the administration of medication however not all staff have completed training for the administration of medication that includes a competency check or a workbook to complete at the end to ensure staff understand their responsibilities. This remains an outstanding requirement from the previous inspection. DS0000000911.V323675.R01.S.doc Version 5.2 Page 17 There are currently no service users self-medicating and no one prescribed controlled drugs, medication records were examined as part of the inspection and found to be in good order. For a particular service user that had an increase in the number of falls, the manager and senior support worker had ensured her safety by initiating a series if actions. The Heath and Safety co ordinator for Avocet trust had undertaken an investigation, risk assessments had been completed, the local authority had been invited to attend a review to discuss the concerns and risks to the service users, the GP had been consulted to rule out any medical reasons for the increase in falls and the staff were being much more vigilant and were awaiting the physiotherapist attend to undertake an assessment. In the meantime the staff were observed to be still promoting the service users independence by ensuring that she still walk around the home but staff providing more support. DS0000000911.V323675.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The staff team are aware of the Protection of Vulnerable Adults policies and procedures and their responsibility within these and the detailed individual plans, behaviour management strategies and attention to health needs ensures that service users are protected from abuse, neglect and harm. EVIDENCE: There had been one formal complaint to the home since the previous inspection, which had been investigated by the home manager however the complainant was dissatisfied that Avocet trust senior management team had not responded appropriately The relative stated ““ Complaint was dealt with by home staff but very little response to it given by Avocet trust management and certainly not dealt with.” Avocet trust must investigate this complaint fully and respond appropriately to the complainant. There has been one safeguarding Adults Investigation since the previous inspection however the outcome was inconclusive. DS0000000911.V323675.R01.S.doc Version 5.2 Page 19 From examination of the training records it was evident that all staff have completed training in the Protection Of Vulnerable Adults Policies and Procedures and therefore understand their responsibilities within this and the detailed individual plans, behaviour management strategies and attention to health needs ensures that service users are protected from abuse, neglect and harm. DS0000000911.V323675.R01.S.doc Version 5.2 Page 20 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): 24,27,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a safe, attractive and homely place in which to live that meets their needs. EVIDENCE: 199a-203a Saltshouse Road consists of three separate units registered to provide care for 8 service users with a learning disability. The property is set back from the main road in the corner of a new residential estate, built in the old grounds of Tilworth Grange Hospital. 199a has three bedrooms one upstairs; all other accommodation is at ground floor level. DS0000000911.V323675.R01.S.doc Version 5.2 Page 21 201a has two bedrooms and 203a has three. All bedrooms are singles four of which have ensuite facilities. Each unit has it’s own lounge, dining room, laundry room and shared bathroom. All units have their own front door and separate garden areas to the rear. The properties adjoin each other and share a large communal patio / garden at the front. Nearby there is a range of local shops, pubs, and health services. Public transport to various parts of the city is easily accessible and in addition some of the service users have leased their own cars; arranged through their mobility benefits. The home presents as bright, cheery, homely and comfortable and at the time of the inspection was very tastefully decorated for the Christmas celebrations. The manager has a plan for the routine redecoration of the home ensuring that it is clean and well decorated at all times. The majority of maintenance certificates were seen and were up to date meaning that service users live in a safe, comfortable and homely environment. Equipment was available to maximise service users independence and serviced appropriately. At the previous inspection the home had received a letter from a relative of one of the service users living in the house highlighting the lack of privacy and dignity afforded to the service user when using the WC. The inspector discussed this with the manager and staff of the house. The house has only one bathroom without a WC and a separate WC facility for service users and staff in the house. The particular service user prefers to take her time and leave the door open, which opens directly onto the corridor and therefore does not protect her privacy and dignity. The service users plan has been amended to reflect this area of need and this is now being managed more effectively by the staff however the relative is not satisfied by the lack of response from Avocet trust senor management team and this must be addressed. DS0000000911.V323675.R01.S.doc Version 5.2 Page 22 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): 32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are met by a stable, competent and qualified staff team that are aware of service users complex needs and are able to meet them EVIDENCE: From examination of records, discussion with staff and observation it was evident that staff work to support the written aims and objectives of the home. It was also evident from discussion with staff that they knew how to meet the needs of service users and there was good evidence in case files and records of the involvement of other agencies with specific expertise. It was evident that the manager and staff had well-developed relationships with service users. DS0000000911.V323675.R01.S.doc Version 5.2 Page 23 Each house has different staffing levels; 199a has a minimum of 2 staff during the day and 1 waking night staff, with additional staff brought in for activities. 201a has 1; 1 staffing for the two service users all day from 8.00 am to 10.00pm and 1 waking night staff. 203a has a minimum of 2 staff during the day and 1 waking night staff with additional staff brought in for activities. Staff spoken to confirmed that this was adequate staffing to meet service users needs. Throughout the inspection it was evident that staff respected service users and were seen to be accessible, approachable, and comfortable with them. The manager had an up to date list of the staff working at Saltshouse Rd. There has been some staff changes at the home since the previous inspection, three staff have transferred to other services within Avocet trust and there has been one new staff transferred from another service to Saltshouse rd and three new appointments to the home. All of this movement has had an impact on the numbers of staff qualified to NVQ level 2, the manager confirmed that out of 31 staff 12 staff have got NVQ level 2 or above and some are working towards it therefore she did not yet have 50 of staff that have achieved NVQ level 2. This is an outstanding requirement from the previous inspection. The staff recruitment records for the recently appointed staff were examined and all had an up to date CRB disclosure and written references obtained and all of the ID required by schedule 2. From examination of records and discussion with the manager and staff there was some evidence of training and this was linked to the needs of service users, all staff were up to date with their mandatory training and had received training in safeguarding adults however not all had received appropriate medication training. The manager had completed an audit of the training clearly identifying where the gaps in staff skills were and two of the new staff have commenced LDAF induction. DS0000000911.V323675.R01.S.doc Version 5.2 Page 24 During the inspection it was evident that staff respected service users. It was evident from discussion with staff that they felt they were able to meet the service user’s needs. Since the previous inspection all staff have had an annual appraisal which details their training needs. The manager and senior staff are providing very good supervision which is detailed in its content and is regular, any issues of competence or staff disagrements are adressed and resolved leading to a harmonious staff team that meets service users needs in a consistent and reliable manner. DS0000000911.V323675.R01.S.doc Version 5.2 Page 25 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): 37,39,42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The manager provides effective leadership; guidance and direction to staff to ensure that service users receive consistent quality care promoting and safeguarding the health, safety and welfare of the people using the service. EVIDENCE: The manager- Carole Osbourne is registered as the manager of Saltshouse rd with the CSCI and she has recently completed the registered managers award. Staff spoken to commented that the manager is very supportive. They also stated that she is very approachable. DS0000000911.V323675.R01.S.doc Version 5.2 Page 26 The home is safe and comfortable for people living there and provides a clean, comfortable and homely environment. Avocet have developed a quality assurance system and this together with the managers own internal monitoring and review systems means that the standard of the service is overall very good. However there was no evidence that service users and their families views are utilised to help shape the way the service is provided and if this were to be in place it would further develop the system. As part of the inspection the majority of the maintenance records were examined and those seen were in order. However there was no evidence that the electrical hard wiring had been tested and no evidence that the water systems were free from the legionella bacteria. All of Avocets policies and procedures have been reviewed and amended to ensure that staff are aware of their responsibilities and are able to protect service users from harm. The Manager reported that budgets are set by the provider and she has responsibility for managing a range of budgets e.g. staffing, food, petty cash,and training. Some staff raised concern that some of the budgets had been reduced in this financial year, however in discussion with the manager the inspector was reassured that although this had been the case following negotiations with the finance director the budgets would be increased back to their original figure for the next financial year. The manager stated that the home always has enough money for food, cleaning, activities etc. As a result of staff feedback and concerns raised re the management of the service users finances this was discussed with the manager. The inspector was informed that as a result of the new Money Laundering Act that The Finance director for Avocet trust had stated that all service users had had to move their their bank accounts. Staff were concerned that there had been no consultation with service users, their relatives and/or advocates. The manager had also raised a number of concerns with the Finance Director in management meetings, supervisions and in letters, re lack of notification, new cheque books being issued and no funds transferred therefore service users new accounts going overdrawn, service users monies being held in an Avocet Trust holding account and concerns re service users losing the interest on their money, large amounts of bank charges being accrued by service users and the slow pace of transferring service user funds to the new accounts. The manager said she had received assurances form the Finance director that all DS0000000911.V323675.R01.S.doc Version 5.2 Page 27 bank charges would be reimbursed and interest accrued re paid to the service users. The manager is keeping a detailed spread sheet of all transactions and charges accrued and is monitoring the situation very closely, she assured the inspector that she will personally ensure that none of the service users loses any of their money due to this situation of which she had no say in or control over. The inspector has passed these concerns over to the Local Authority commissioning unit for investigation and to obtain some clarity regarding the situation. DS0000000911.V323675.R01.S.doc Version 5.2 Page 28 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 3 28 x 29 3 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 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 2 x x 4 3 x x 2 x DS0000000911.V323675.R01.S.doc Version 5.2 Page 29 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 YA20 Regulation 13 Requirement The registered person must ensure that all staff complete their training in the safe handling of medication and are assessed as competent. (Timescale of 30/09/05 and 31/03/06 not met) The registered person must ensure that complaints are responded to formally ensuring that complainants are satisfied that their concerns have been addressed and giving an opportunity to take concerns further if they wish to. The registered person must ensure that at least 50 of staff are qualified to NVQ level 2. (Timescale of 1/12/05 and 30/06/06 not met) The registered person must ensure that a training plan is developed for the staff team in the home. (Timescale of 31/03/06 not met) The registered person must provide evidence that the DS0000000911.V323675.R01.S.doc Timescale for action 31/03/07 2 YA22 22 31/01/07 3. YA32 18 30/09/07 4. YA35 18 31/03/07 5 YA42 23 31/01/07 Version 5.2 Page 30 electrical hard wiring has been tested and is safe and that the water systems are free for legionella bacteria. 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 YA39 Good Practice Recommendations The registered person should further develop the quality monitoring system within the home to take into account service users, relatives and stakeholders views and any actions are taken to improve the overall standards within the home. DS0000000911.V323675.R01.S.doc Version 5.2 Page 31 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 DS0000000911.V323675.R01.S.doc Version 5.2 Page 32 - 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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