Inspection on 21/11/06 for Scope - Warrington Road

This inspection was carried out on 21st November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Scope - Warrington Road 17/04/07

Scope - Warrington Road 13/12/05

Scope - Warrington Road 22/06/05

Scope - Warrington Road 10/01/05

Scope - Warrington Road 23/07/04

Scope - Warrington Road 12/03/04

Similar services:

Ruskin Lodge

Dystlegh Grange

The Good Companions

Springfield Cottage

Cuerden Grange Rest Home

Cornmill Nursing Home

Vitalise Sandpipers Centre

Sue Ryder Care Birchley Hall

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

CARE HOME ADULTS 18-65 Scope 102 to 108 Warrington Road Widnes Cheshire WA8 0AS Lead Inspector Maureen Brown Key Unannounced Inspection 21 November 2006 10:00 Scope DS0000005181.V293177.R01.S.doc Version 5.1 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 Scope DS0000005181.V293177.R01.S.doc Version 5.1 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. Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Scope Address 102 to 108 Warrington Road Widnes Cheshire WA8 0AS 0151 495 1256 0151 423 3621 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) SCOPE Ms Paula Smith Care Home 12 Category(ies) of Physical disability (12) registration, with number of places Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 12 service users in the category of PD (Physical disability) 13th December 2005 Date of last inspection Brief Description of the Service: 102 -108 Warrington Road is a residential care home providing personal care and accommodation for 12 young adults with a physical disability. The premises are owned by Liverpool Housing Trust, and are managed by Scope, a national organisation for people with cerebral palsy. All of the service users have their own individual tenancy agreements. The home is located approximately three quarters of a mile from Widnes town centre and is close to a church, shops and a pub. There are limited car parking facilities at the home. On the road parking is available in front of the property. Warrington Road comprises four purpose built bungalows, each with a kitchen/dining area, lounge, three bedrooms, bathroom, shower room and a utility area. 104 and 106 each have one additional room set off the main areas of the bungalows. The room in 104 is used as an office and the room in 106 has been used for sleep in purposes in the past. It is currently being used as a storeroom. The home has patio and garden areas, which are and easily accessible. The staff team consists of the registered manager who is supported by a team leader, two senior support workers and seventeen support workers. The fees at Warrington Road are between £33,973.00 and £54,524.00 per year. Fees are calculated on individual assessment. Optional extras include CD’s, Videos, DVD’s, holidays, magazines, clothing, toiletries, transport costs and hairdressing. Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit took place on 21 November 2006 and lasted 6.25 hours. Maureen Brown carried out the visit. This visit was just one part of the inspection. Before the visit the home was also asked to complete a questionnaire to provide up to date information about services at the home. Questionnaires were also made available for service users, relatives and other professionals to find out their views. Other information since the last key inspection was also reviewed. During the visit various records and the premises were looked at. A number of service users and staff were also spoken with and they gave their views about the service. Twenty-four standards were assessed including all the key standards and most were met. The overall quality rating for Warrington Road is good. Feedback was given to the team leader at the end of the visit. What the service does well: What has improved since the last inspection? Some improvement of care plans had been made. The service user or their representative and the manager had signed the contract. Risk assessments are now up to date and service users daily records have improved. The standard of the furnishings has been addressed. The carpets in bedrooms and corridors have been deep cleaned. The lounge carpet in Bungalow 102 has been replaced. The bath panel has been replaced and the marks on the kitchen floors have been attended to. Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 6 To show that service users are receiving care from staff that have been properly vetted all pre-employment checks are now completed. To ensure the ongoing welfare and safety of service users the emergency lighting is checked on a monthly basis. What they could do better: Completion of care plans should continue to be improved. The service users’ healthcare needs records should be kept up to date, copies of the social services reviews should be kept on file at the home. Also staff should review the care plans on a monthly basis with records kept. To ensure that service users receive an appropriate diet of their choosing dietary reviews should be undertaken with all service users and a balanced diet encouraged. To ensure that service users are protected by robust medication procedures the date should be recorded on creams to ensure that ones requiring disposal after 28 days are monitored and all medication should be kept secure. The standard of the environment should be addressed. The corridors and doorways should be repaired and redecorated to improve the environment to a better standard for the service users. To ensure that service users are looked after by suitably qualified staff a plan to show how 50 of care staff will be trained to NVQ level II or above should be produced. To ensure that service users are looked after by supported staff the staff must receive an annual appraisal. The educational needs of service users continue to be fully explored. To ensure the ongoing welfare and safety of service users the recorded water temperatures should be monitored and appropriate action is taken when these are below recommended guidance. Documentation within the home should be provided in a format that is easily understood by the client group. Therefore the home should consider alternative formats for the statement of purpose and function and service users guide. Also the CSCI details should be included in the Complaints booklet and details of NCSC removed. Within the quality assurance process views of family members and visiting professionals should be obtained to ensure that the home is run in the best interests of the service users. Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 7 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. Scope DS0000005181.V293177.R01.S.doc Version 5.1 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 Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this area outcome is good. This judgement was made using available evidence including a visit to this service. Sufficient information is provided for service users to make a decision about moving into the home. EVIDENCE: The statement of purpose and function was seen on each service users file. These were in large print format. A recommendation was made with regard to exploring different formats for this document to that the information could be easily understood. Care plans examined showed that assessments had been carried out with each person before moving into the home. Service users had visited the home prior to admission and trial overnight visits were encouraged. Admissions were planned and ranged from a short visit to overnight stays, dependent on the needs and wishes of the person. Each service user has a tenancy agreement, which is known as the service delivery agreement. This includes information on the terms and conditions of residence, fees charged and the rights and responsibilities of both parties, and covers all the areas with in the service users guide. The service user or their representative and the registered manager had signed the contract. Scope DS0000005181.V293177.R01.S.doc Version 5.1 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 & 9 Quality in this area outcome is good. This judgement was made using available evidence including a visit to this service. The service users’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. EVIDENCE: Three service users’ care files were seen during this visit. These were comprehensive and well presented in individual folders. Each contained all the information required by staff to adequately care for the service users. Included were care plan monitoring sheets, 24-hour summary sheets and visiting professionals sheets. Risk assessments had been brought up to date following a previous requirement. The care plans were drawn up in consultation with the service users and family and were based on their assessed needs and risks. The care plans reviewed on an annual basis by social services and in conjunction with the service users, had been brought up to date following a previous requirement. Staff should review the care plans on a monthly basis and keep records. Daily record sheets seen showed that day-to-day activities were recorded. This enabled staff and family members to see what a particular service user Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 11 was undertaking during the day. Carers signed them. These had improved since the previous visit. Service users confirmed they had chosen the décor and furniture within their own bedrooms and it was seen that each bedroom reflected service users’ personality and preferred taste of décor. The staff said that all service users had been involved in choosing the décor of the shared rooms. Service users’ meetings had been started following a previous recommendation. The first meeting was held in October and all service users attended. Discussions included the budget for the next financial year, new gardener and care profiles. Notes were available from the meeting and the next meeting was due to be undertaken. Scope DS0000005181.V293177.R01.S.doc Version 5.1 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 & 17 Quality in this area outcome is adequate. This judgement was made using available evidence including a visit to this service. Service users’ were able to take part in a range of activities, but educational needs were not fully met. Personal and family relationships were encouraged by the home and the staff team supported people with this. EVIDENCE: The service users’ plans reflect the range of activities undertaken which included attending “lifestyles” day centre where a programme of crafts, music, information technology, working on an allotment, cooking or flower arranging is available. Each service user has three or four sessions a week. The service users also use a local gym for trampoline, boules and snooker. Service users spoken to said they enjoy going out and about in the community, to local shops, out for lunch, to the pub or cinema. The home has a wheelchairadapted vehicle, which all service users can access. From the previous recommendation educational needs were not fully met at this time, however, the manager had contacted the local colleges and was waiting for a response regarding suitable courses available to the service Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 13 users. The manager has agreed to follow this up. Although this area is not fully met opportunities for residents to continue learning are being promoted by the home. Visits from family and friends was recorded in the care plans and case notes. Service users shared with the inspector the contact they had with family members and said they could choose to see visitors within their own room or in the shared lounge/dining area. Each service user’s menu was recorded across the day in the diary. These showed a diet with a variety of meat, fish and cheese was provided to the service users. However the menu lacked a choice of fresh vegetables, fruit and desserts. On rare occasions vegetables were served. Staff confirmed that service users did not particularly like fresh vegetables or fruit. It was noted on a tour of the premises that fresh fruit was available within the bungalows. Staff encouraged service users to eat a balanced diet. A recommendation was made to complete dietary reviews with service users to ensure a balanced diet was being given. One service user said “the meals are good here, plenty of variety and we choose the menus”. “If you don’t like what is on the menu then an alternative meal is offered”. Scope DS0000005181.V293177.R01.S.doc Version 5.1 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 & 20 Quality in this area outcome is adequate. This judgement was made using available evidence including a visit to this service. The service users’ basic health, personal and social care needs are met and the service users received support from the staff for health care in accordance with their stated preference. EVIDENCE: The sample 24-hour summary records seen described how the service users preferred to be supported in their daily routines. These were written in the first person. Times for rising and resting preferred moving and handling techniques and personal care preferences were recorded, as was choice of clothing, hairstyle and makeup. All service users were dressed differently according to their own choice. Visits to health professionals were recorded in the care plans, including visits to GP’s, opticians, chiropodists and dentists. However this information was difficult to access easily as visiting professional sheets were not completed. Appointments with consultants and other hospital appointments were also undertaken. The previous requirement regarding this had not been met, and the requirement was reiterated. The manager said a carer always attended appointments with service users. Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 15 The medication system is kept in a locked steel cupboard within the bathroom of each bungalow. A monitored dosage system was used. It was recommended that the date is recorded when creams are opened so that ones requiring disposal in 28 days can be monitored. The medication administration sheets seen were signed and up to date. Drugs are returned on a monthly basis. Staff are trained in medication awareness. Staff files examined showed medication training undertaken. A medication policy and homely remedies sheets were available to staff. The manager stated that they were considering storage of medication in service users own bedrooms within locked facilities. During a tour of the home it was noted that one of the medication cupboards could not be made secure. It was recommended that medication must be kept secure for all service users. The manager stated that this would be made secure. Scope DS0000005181.V293177.R01.S.doc Version 5.1 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 & 23 Quality in this area outcome is good. This judgement was made using available evidence including a visit to this service. Service users and relatives were satisfied with the support they received from the manager and staff. Clear policies and procedures were in place to ensure that service users were protected from abuse, neglect and self-harm. EVIDENCE: The home’s policy on complaints was seen. This booklet is produced in large print and written in plain English. The home needs to change NCSC to CSCI details. Service users confirmed they would speak to the staff if they had a complaint. Staff confirmed that they were aware of the procedure and would pass concerns onto the manager. No complaints had been received by the home or the Commission since the last visit. All the service users said that they knew who to speak to if they were unhappy with their care. The home’s Protection of Vulnerable Adults Policy was consistent with the “No Secrets” guidance from the Department of Health. A copy of Halton Social Services’ policy on Adult Protection was available within the home and was accessible to staff. Policies on whistle-blowing and challenging behaviour were also available. Discussions were held with the manager about Adult Protection procedures and she was able to demonstrate the procedure to be followed in this situation. She is also the Designated Adult Protection Advisor (DAPA). Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 17 Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this area outcome is adequate. This judgement was made using available evidence including a visit to this service. The home provides a clean but adequately maintained environment for the people to live in. EVIDENCE: All four bungalows were visited at this time. Each was furnished in a domestic style with additional equipment such as hoists and tracking provided as necessary to meet the service users’ needs. Service users said that bedrooms were decorated to their preferred style. The staff stated that shared lounge and dining areas were decorated with service users’ involvement in the colour scheme chosen. Each bungalow was generally clean, tidy and free from any unpleasant smells. However, although the bedrooms and lounges were in a good state of décor and repair the corridors and doorways into communal areas and bedrooms were not in a good state of repair and décor. A discussion was undertaken with the manager and she stated that the housing association was responsible for the decoration of the building and the current contract states that communal areas will be decorated every five years. It was evident that Scope had also decorated in between this timescale but it appeared this was not frequent enough to maintain a good environment for the service users. It is Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 19 acknowledged that that damage caused by wheelchairs to the walls in the corridors and doorways into bedrooms and communal areas is a problem but a resolution to this should be sought. Discussions were held regarding more frequent decoration of these areas either by the housing trust or Scope and possibly some form of protection for these areas. However, despite the problems faced with these areas it is acknowledged that the home have tried hard to keep on top of the decorating and are currently redecorating which should improve these areas further. At the previous visit requirements were made regarding the following: 1. Some bedroom and corridor carpets needed deep cleaning; 2. The lounge carpet in Bungalow 102 needed replacing; 3. The bath panel needed replacing; and 4. The flooring in most kitchens was badly marked and needed attention. All these areas had been attended to satisfactorily. The carpets were being regularly deep cleaned by an outside company. The bath panel and lounge carpet had been replaced and the marks on the kitchen flooring had removed. However it was noted that these had returned after a few weeks and were caused by the rubber on the wheels of the electric wheelchairs. Other areas of improvement made since the last visit included new carpets in two of the halls and two lounges. A new gardener has been employed and the manager confirmed that this appears to be working well. The gardens were tidy at the time of this visit. Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this area outcome is good. This judgement was made using available evidence including a visit to this service. Records were well maintained and service users are protected by the homes recruitment policy and practices, which are consistently followed. EVIDENCE: On arrival at the home four care staff and two seniors were on duty. The homes manager and team leader were due in later that morning. Five staff had obtained NVQ level II in Care and six staff were undertaking this award. Mandatory training included moving and handling, first aid, fire awareness, food hygiene and medication training. All staff had completed mandatory training. Health and Safety and Adult Protection were other courses most staff had undertaken. Three staff files were examined and these showed that pre-employment checks were carried out. These included proof of identity, health declarations, application forms, two references and Criminal Record Bureau checks. It was noted that some staff who had worked at the home for a long time did not have the same level of checks that are now required. Full employment checks are carried out for all new staff members. Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 21 A new induction programme had been developed and this is being cascaded to all staff at the time of this visit. Day to day supervision of the staff team is received good support from the manager. and a sample of these records were seen. undertaken with about half the staff team. should receive an appraisal. good. Staff commented that they Formal supervision was up to date Annual appraisals had been It was recommended that all staff Staff meetings were held. The last meeting was on 3 November 2006 with ten staff attending (about half the staff team). Issues discussed included senior team leader roles, meals, professionalism, attitudes and approach of staff, agency staff, adult protection training, health and safety and AOB. The previous meeting was held on 29 September 2006. Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this area outcome is good. This judgement was made using available evidence including a visit to this service. The health, safety and welfare of the service users are protected. The views of service users are obtained and influence the running of the home. Service users receive support from staff that are not fully supervised. EVIDENCE: Safe working practices included visits from the fire safety officer and the environmental health officer, which had been completed satisfactorily. The gas safety, electrical safety and insurance certificates were in place and up to date. Fire alarm tests were being undertaken on a weekly basis and records kept. Following a previous recommendation the emergency lighting tests are now carried out on a monthly basis with records kept. It was noted that the records of water temperatures in one of the bungalows were 36 degrees, which is significantly below the recommended temperature of 42 degrees. It was suggested that this be checked and increased as appropriate. Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 23 Completed service users surveys were available. Ten service users had completed the questionnaires. The survey had been completed in 2005. Responses had been collated and this information had been shared with service users in house meetings. Copies of these were seen. Comments from service users included “sometimes we cannot get a vehicle and I have to wait”, “I would like to spend more time with people who are not involved in Scope” and “my family are involved in my review”. Also “I would like to get out more” and “I go to the day centre, I have been to college in the past but do not wish to go in the future”. During discussions with the manager it was identified that feedback was not formally received from families and other visiting professionals. This information was received during reviews and on contact with GP’s. It was suggested that this process be formalised. The manager has worked for Scope for fifteen years, seven of which as manager. She has NVQ level IV Registered Managers Award and Designated Adult Protection Advisor (DAPA). She has also undertaken other relevant courses to update his skills and knowledge. Scope DS0000005181.V293177.R01.S.doc Version 5.1 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 3 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Scope DS0000005181.V293177.R01.S.doc Version 5.1 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 YA19 Regulation 13 Requirement The registered person must ensure that service users’ healthcare needs are kept up to date. Previous timescale of 31/03/06 not met. The registered person must ensure that the corridors and doorways are repaired and redecorated to improve the environment for the service users. Timescale for action 30/01/07 2 YA24 23(2) 15/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA1 YA6 YA7 Good Practice Recommendations The registered person should consider alternative formats for the statement of purpose and function and service users guide. The registered person should ensure that staff review the care plans on a monthly basis with records kept. The registered person should ensure that copies of the social services reviews are kept on file at the home. DS0000005181.V293177.R01.S.doc Version 5.1 Page 26 Scope 4 5 6 7 8 9 10 11 12 YA12 YA17 YA20 YA20 YA22 YA32 YA36 YA39 YA42 The registered person should pursue educational courses on behalf of the service users. The registered person should ensure that dietary reviews are undertaken with all service users to ensure that a balanced diet is encouraged. The registered person should ensure that the date is recorded on creams to ensure that ones requiring disposal after 28 days are monitored. The registered person should ensure that all medication is kept secure. The registered person should ensure that CSCI details are included in the Complaints booklet. The registered person should produce a plan to show how 50 of care staff will be trained to NVQ level II or above. The registered person should ensure that all staff receive an annual appraisal. The registered person should consider formalising the views from family members and visiting professionals with regard the quality assurance process. The registered person should ensure that the recorded water temperatures are monitored and appropriate action is taken when these are below recommended guidance. Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Scope DS0000005181.V293177.R01.S.doc Version 5.1 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!