Inspection on 22/08/06 for Shamrock House

This inspection was carried out on 22nd August 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shamrock House 17/02/09

Shamrock House 11/12/07

Shamrock House 06/12/05

Shamrock House 05/07/05

Shamrock House 26/10/04

Shamrock House 20/05/04

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

CARE HOME ADULTS 18-65 Shamrock House 69 Hook Road Goole East Yorkshire DN14 5JN Lead Inspector David White Key Unannounced Inspection 22nd August 2006 09:00 Shamrock House DS0000019723.V306847.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 Shamrock House DS0000019723.V306847.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. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shamrock House Address 69 Hook Road Goole East Yorkshire DN14 5JN 01405 766217 01405 766217 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) Mrs Lila Chaudhary Mrs Marcia Dorothy Nicholls Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (5) Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The category MD(E) refers to only five (5) named individuals already resident within the home. 6th December 2005 Date of last inspection Brief Description of the Service: Shamrock House is a care home, which provides twelve placements for male and female service users with mental health problems, and aims to enable them towards independent living. Bedroom accommodation is mostly in shared rooms. Service users have the opportunity to mix in the communal areas, which consists of a lounge, conservatory and a dining room. The garden area is accessible to wheelchair users, although the homes two bathrooms are situated upstairs and therefore the accommodation is limited for those with mobility problems. The location of the home close to the centre of Goole ensures that there is good access to the local bus and train services for both service users and their visitors. The current fees at the time of the site visit on 22nd August 2006 ranged from £260.80 to £479.40 per week and do not include costs for hairdressing, toiletries and activities. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced site visit undertaken on the 22nd August 2006. This visit was carried out by one Regulation Inspector and took 7.5 hours with 6 hours preparation time. The home was able to return the requested information before this site visit, and surveys were sent out to relatives and other professionals who had contact with the home. Surveys were received from three relatives, a GP and three health/social care professionals. Information was also used from the Regulation Inspector’s inspection record, which detailed the history of the home and relevant information about what had been happening in the home since the previous inspection visit. The site visit comprised of a full inspection of the premises. The care records of three service users were looked at which included service users assessments, care plans and medication records. Staff rotas and health and safety documentation were inspected. Time was spent talking to three service users, three members of care staff, the administrator and the manager of the home. The activity in the home and the interaction between service users and staff was observed. The focus of the inspection was on a number of key standards and inspecting the case records of a number of service users to establish whether they corresponded with their experiences of life in the home. The manager was available throughout the site visit and the findings were discussed at the end of the visit. What the service does well: Good pre-admission procedures ensured that prospective service users’ were only admitted to the home if the staff team were able to meet their needs. Surveys received from relatives all said that they were kept well informed about their relative’s care and this reassured them. Service users’ said that the quality of the meals was “good and varied”. Service users’ had access to a range of activities to enable them to pursue their educational, social and leisure interests. Service users’ were given the opportunity to voice their views and contribute towards how the home was run. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 6 All the service users’ said that the staff were “friendly and helpful” and this made them easy to approach for support and assistance. What has improved since the last inspection? What they could do better: Care plans need to be in more detail so that staff are fully aware of what actions are needed to meet service users’ needs. Plans to manage any identified risks for each service user need to be agreed and signed by the service user to show that they are in agreement with the intended actions being taken in order to safeguard their interests. All staff need to receive some updated abuse awareness training so that they are fully aware of how to protect service users from risk of harm and how to make referrals to social services if concerns arise. Urgent action must be taken by the registered provider to ensure that proper pre-employment checks are made on all staff prior to them taking up their post so that service users are not put at risk of potential harm. A formal letter was left at the site visit requiring the provider to deal with this problem. Urgent action must be taken to secure hazardous chemicals and used disposable razor blades must be discarded and not left in bathrooms to prevent risks of harm to the health and safety of the service users’. A formal letter was left at the site visit requiring the provider to deal with this problem. Staff need to have training in mental health so that they have a better understanding of the needs of people with mental health problems. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 7 All staff need updated training in first aid, moving and handling, health and safety, fire safety and abuse awareness to ensure that their working practices are safe and the interests of service users’ are safeguarded. The registered person must make a report of her findings from her unannounced visits to the home providing information about her findings and actions taken to improve the overall service. 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. Shamrock House DS0000019723.V306847.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 Shamrock House DS0000019723.V306847.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 5. Quality in this outcome area was good. This judgement had been made using available evidence including a visit to this service. Detailed information about service users’ had been obtained before they were admitted to the home to ensure that service users’ needs would be met properly. EVIDENCE: Service users’ and their representatives were given copies of the home’s statement of purpose and service user guide before they were admitted to the home. The manager of the home carried out the pre-admission assessments of prospective service users and information from other sources such as GP’s and social services had been obtained prior to the admission of a service user. An assessment of individual needs was carried out by the home as part of the assessment process. Three service users’ care records were inspected and these all contained an initial assessment and care plan from the placing authority which clearly detailed the specific individual needs of the service users’. Each service user had an individual contract that had been agreed between the home and the service user and a recently admitted service user said that they had visited the home before making a decision to move there. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 10 Service users’ felt that the care they received was good and that their needs were being met. However staff had still not received any specialist mental health training despite the manager’s attempts to access some training in this area in order to better equip staff to be able to understand and meet the specific needs of people with mental health problems. Shamrock House DS0000019723.V306847.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area was adequate. This judgement had been made using available evidence including a visit to this service. Improvements were needed to the care planning documentation to ensure that service users’ needs were fully met. EVIDENCE: Service users’ looked well cared for and some made comments about the care they received. One service user said, “staff were helpful and supportive” and another commented that the staff “help to reduce my stress”. Service users’ said they were encouraged to make their own choices about their preferred daily routines and felt their independence was encouraged. They were able to confirm that they were involved in their care plan reviews if they wanted to be. A survey received from a health and social care professional indicated that staff at the home did not always have a good understanding of the service users’ needs. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 12 Staff spoken did demonstrate some knowledge of the individual needs of the service users’ but would benefit from a better understanding of the specific needs of people with mental health problems in order to meet all the service users’ needs. The care plans of three service users’ were looked at. Whilst the care plans reflected the assessed needs from the pre-admission information they did not give enough information about the personal care needs of the individuals and there was little guidance for staff as to how individual care should be delivered and this lack of information could lead to service users’ care needs not being met. Service users’ had signed their care plans to show their agreement with what was being written in them. Individual risk assessments had been carried out on all the service users’ and there were risk management plans in place to safeguard the interests of the service users’. However there was no written evidence that service users’ were in agreement with the risk management plans and therefore it was not clear as to whether service users’ agreed with the actions being taken. The home had daily report sheets to record daily activities, which were kept up to date and included input from other healthcare professionals. However entries within the report sheets were mostly basic, lacked detail and did not always reflect the care that was being provided and activities being undertaken by the service users’. Shamrock House DS0000019723.V306847.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area was good. This judgement had been made using available evidence including a visit to this service. Service users’ enjoy a range of activities to meet their social and recreational needs. EVIDENCE: Service users’ said that they had opportunities to participate in a number of different activities. Some of the service users’ attended the local Sobriety Centre where they enjoyed Arts and Craft sessions. One service user said they particularly enjoyed the gardening groups run by the Green Team and service users’ could access the local MIND centre. Adult education classes were available at the local college and one service user was attending the college to take part in literacy classes. A number of the service users’ visit the community facilities such as the local pub and swimming baths and a number of service users had recently been on a day outing to Bridlington. One service user who had recently been admitted to the home had been a lifelong football fan and had a season ticket to watch his local team which he said he had been able to pursue since living at the home. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 14 All the service users’ spoken to said that they got on with each other and the service users’ present at the time of the site visit could be seen to be interacting well together. Visiting arrangements were flexible and service users’ could see family and friends whenever they wanted and one of the service users’ had planned a holiday with their family. The home had a telephone for service users’ to use if they wished to communicate via this manner. There was an opportunity for service users’ to attend local church services if they wished to do so. Service users’ were complimentary about the standard of the food at the home. Menus tended to be planned on a weekly basis and were then displayed on a board. Service users’ were able to confirm that they could have an alternative meal if they did not like the food on the menu on a particular day and extra foods were bought in advance for this purpose. All the staff had recently attended some updated food hygiene training. A survey was received from a relative expressing concerns about the number of flies at the home and the effect this was having when people were eating. A mealtime was observed at the site visit and service users’ could be seen eating their meals without the presence of any flies. One service user said that there had been a problem with flies a few weeks earlier but this had not affected people whilst they were eating their meals or the quality of the food provided. Shamrock House DS0000019723.V306847.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area was good. This judgement had been made using available evidence including a site visit. Service users’ received personal support in accordance with their wishes and had access to specialist services when required to ensure that their healthcare needs were met. EVIDENCE: Most of the service users’ maintained their own personal cares. When needed staff could be observed to be providing support in a dignified manner. One service said “the staff are kind and even though I need very little support I know that staff will always help me if I need it”. Surveys received from three relatives, a GP and a health and social care professional expressed satisfaction with the care provided by the home. One comment received from a health and social care professional indicated that there was not always a senior person to confer with. This was discussed with the manager who said that there was always at least one senior member on duty at all times and the duty rotas were able to confirm this. The manager said that requests to other agencies for urgent assessments were rarely made due to the lack of need and the individual care records looked at supported this. Each service user had a GP and access to other healthcare services and referrals to specialist services were made as required. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 16 The home’s medication system and facilities were inspected and found to be satisfactory. The Medication Administration Records (MAR) were accurate and a random check of the medication supplies tallied with the records. All staff had attended some medication training to update their skills and knowledge. The manager had attempted to address the gender imbalance with the staff team however there had been no interest from male applicants for vacant staff posts. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area was adequate. This judgement had been made using available evidence including a visit to this service. A complaints policy and procedure was in place to address any concerns, however updated abuse awareness training was needed along with an improvement in staff’s knowledge of adult protection procedures to ensure that service users’ were safeguarded from harm. EVIDENCE: The home had a complaints policy and procedure on display at the home that detailed how complaints would be dealt with. Each service user had a copy of the complaints procedure and service users’ knew whom they needed to speak to if they had a complaint and had confidence that their concerns would be dealt with properly. Two surveys received from relatives stated that they were not aware of the home’s complaints procedures and the manager needed to consider how the complaints procedure was made available to all relatives including those who did not or who rarely visited the home. The home had not received any complaints since the previous inspection. The home had a policy and procedure in place for the protection of vulnerable adults. However staff said they had not attended any recent abuse awareness training and the training records showed that there had been no training in relation to adult protection matters since 2004. The manager and staff were asked about adult protection policies and procedures and whilst they demonstrated an understanding of what would constitute abuse they were not clear about what action would need to be taken and who by if abuse had happened or was suspected and this lack of knowledge could put service users’ at risk of harm. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 18 Since the previous inspection the home’s financial systems had improved so that service users’ monies could be accounted for. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area was adequate. This judgement had been made using available evidence including a visit to this service. The environment was comfortable for service users’, however improvements were needed to care practices to make sure the environment was safe for service users’. EVIDENCE: On the day of the site visit the home was warm and bright and free from offensive odours. The home had an ongoing refurbishment programme and the lounge had recently been re-decorated and a new carpet had been fitted and the kitchen had a new cooker. Service users accommodation was over three floors, which could only be accessed via some stairs so the home was not suitable to people with mobility problems. Bedrooms and communal areas were clean and tidy and service users’ said that they were pleased with their living environment. Most of the service users’ had shared bedrooms and these had screens to offer privacy and it was observed that service users’ had personal belongings in their bedrooms. Service users’ looked comfortable and could sit in lounge areas if they chose to do so. In the kitchen there was a cleaning schedule, which had been signed upon completion of tasks and fridge and freezer temperature checks were carried out on a daily basis to maintain safe food hygiene standards. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 20 Whilst looking around the environment there were some concerns about two health and safety matters. It was observed that chemicals such as bleach were being stored in the laundry room that was open and at times unattended to and so was easily accessible to the service users’ and in the first floor bathroom two used disposable blades had been left lying around. These practices put the service users’ health and safety at risk and immediate requirements were issued in relation to both matters. Pre-set thermostatic valves had been fitted to the water outlets and a random check of the hot water temperatures was found to be within safe limits. The home had a Water Test Certificate for Legionella to confirm that the stored water systems were safe in preventing risks to service users’ health. A survey from a relative indicated that the home had a problem with flies. At the time of the site visit there were no flies in the home and although the manager said that earlier on in the year the home did have flies this had not caused any problems and measures had been taken to try and minimise the number of flies coming into the home. A fire safety risk assessment had been carried out be the home and fire safety equipment tests and maintenance records were up to date. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 21 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 and 36. Quality in this outcome area was adequate. This judgement had been made using available evidence including a site visit to this service. Poor recruitment practices and lack of up to date staff training put service users’ at risk of harm. EVIDENCE: On the day of the site visit there were four members of staff on duty as well as the manager. There were usually at least three members of staff on duty through the day and two staff during the night. Although the care staff carried out cleaning, cooking and laundry duties as part of their daily work, staff said that the staffing levels were good and service users’ needs could be easily met. Service users’ commented that there were “always enough staff on duty” and said that they never had any difficulty accessing staff for assistance. Three staff records were looked at and it was found that in one instance a written reference had not been taken up and in two cases including a member of staff who had been recently been appointed, the required Criminal Record Bureau checks had not been carried out prior to staff starting work at the home. This practice was not acceptable and puts service users’ at risk of potential harm. An immediate requirement was issued in relation to this matter. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 22 Staff had induction when they started work at the home and individual training records confirmed this. Although staff said that they had received some recent food hygiene and medication training and generally had an understanding of service users’ needs, there were no records that any recent training had taken place with regard to abuse awareness, moving and handling, infection control, health and safety and fire safety although staff did say they had monthly fire instruction sessions from the manager of the home. The lack of up to date staff training was discussed with the manager who said she had arranged for some staff to do an occupational health and safety distant learning course that included training on safe working practices. Staff were also in need of specialist mental health training so that they had a better understanding of the needs of people with mental health problems. Two of the staff team had attained NVQ level 2 whilst four other staff were undergoing the training and a rolling programme was planned for other staff to do the NVQ course. Since the previous inspection a training needs analysis had been carried to identify what staff training was needed to equip them in meeting the needs of the service users’. The home had an appraisal system for supporting staff and staff meetings were held on a monthly basis to enable staff to voice their views about the running of the home and these were recorded. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area was adequate. This judgement had been made using available evidence including a visit to this service. Improvements were needed to health and safety, recruitment practices, staff training and record keeping to safeguard the interests and safety of service users’. EVIDENCE: The manager had managed the home for seven years having previously worked in the care sector for a number of years. Despite indications in the past that she may step down as the manager of the home, she said that this was not her intention for the foreseeable future. Service users’ and staff said that the manager was “approachable” and “supportive”. The manager had systems in place to seek the views of service users’ and relatives about the care and services provided by the home. Service users’ and relatives were given questionnaires to give their views and opinions about the service and the house meetings gave service users’ further opportunity to be involved in the running of the home. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 24 Service users’ were involved in their care plan reviews if they wanted to be and their families were invited to attend these meetings at the request of the service user. Discussion with the manager indicated that the registered person was still not completing a report of her findings from her unannounced visits to the home, in accordance with her responsibilities under the Care Homes Regulation 2001. A number of health and safety certificates were looked at and were satisfactory and these included an up to date gas and electrical safety certificate. However there were some concerns about some health and safety and staffing matters. Hazardous chemicals needed to be securely stored and used disposable razor blades needed to be disposed of properly so that service users’ were not at risks to their health and safety. Staff were in need of updated training in a range of safe working practices and the continuing lack of proper preemployment checks before staff started working at the home puts service users’ at risk from abuse. Appropriate arrangements had been made to keep records secure but the standard of record keeping within care planning documentation needed to improve. Service users’ monies were discussed and the financial systems used by the home were looked at. Improvements had been made in the documentation of service users’ monies and each service user’s money was held individually and records were well maintained to account for incoming and outgoing monies. A random check of the monies tallied with the records and service users could have access to their monies at any time. Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 2 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 3 X X 1 X Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA3 Regulation 12 Requirement Timescale for action 22/11/06 2. YA6 15 3. YA9 13 5. YA24 13 The registered person must ensure that staff specialist training and development to equip them with the skills and experience to meet the needs of the service users. (Previous requirement, timescales of 27/3/04, 1/10/05 and 1/4/06 not met). Care plans must be more 22/11/06 detailed so that they clearly state the actions required in order to meet service users’ needs. The registered person must 22/09/06 ensure that risk management strategies have been clearly agreed with service users’. The registered person must 22/08/06 ensure in order to reduce risks to the health and safety of the service users’ that: • Hazardous chemicals must always be securely stored and are not accessible to the service users’. • Used disposable razor blades must be disposed of and not left lying around in communal areas of the home which are accessible to the service users’. DS0000019723.V306847.R01.S.doc Version 5.2 Shamrock House Page 27 6. YA34 19 An immediate requirement was issued at the site visit. The registered person must 22/08/06 ensure that new staff must only be confirmed in post following completion of satisfactory checks to include the receipt of written references and enhanced disclosures from the Criminal Records Bureau so that service users’ are not put at risk from abuse. (Previous requirement, timescale of 6/11/05 not met). An immediate requirement was issued at the site visit. The registered person must make a report of her unannounced visits to the home providing information about her findings and actions taken to improve the overall service and send a copy of these to the Commission for Social Care Inspection. (Previous requirement, timescales of 27/4/04, 1/09/05 and 6/3/06 not met). The registered person is required to make arrangements for all staff to attend the following training: Abuse awareness, health and safety, fire safety, moving and handling and infection control. 7. YA41 26 22/11/06 8. YA42 13 22/11/06 Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA32 YA9 Good Practice Recommendations All the staff in the home work towards NVQ level 2 attainment. The registered person should continue to take steps to address the staff team gender imbalance in order to ensure that the (all) male service users needs are appropriately met. The registered person should consider ways of making sure that relatives who do not visit the home are aware of the home’s complaints procedure. 3. YA22 Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Shamrock House DS0000019723.V306847.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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