Inspection on 12/06/06 for Shamu

This inspection was carried out on 12th June 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shamu 31/07/07

Shamu 02/11/05

Shamu 07/07/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Shamu 126 Regent Road Hanley Stoke on Trent Staffordshire ST1 3AY Lead Inspector Jane Capron Key Unannounced Inspection 12 June 2006 09:30 Shamu DS0000064026.V296880.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 Shamu DS0000064026.V296880.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. Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shamu Address 126 Regent Road Hanley Stoke on Trent Staffordshire ST1 3AY 01782 208590 01782 269187 chris@delamcare.co.uk 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) Delam Care Ltd Mrs Pauline Adams Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd November 2005 Brief Description of the Service: Shamu is a residential care home providing care for six service users who have a learning disability. Some of the service users also experience mental ill health. It is owned by Delam Care, a company that owns five similar care homes in the vicinity. Delam Care has recently been bought by Care Tech. Accommodation is provided in single bedrooms, four of which are located on the ground floor. The communal areas include a lounge and separate dining room, a domestic kitchen and a laundry shared with the adjacent care home. The home has a small garden area at the front and a larger area at the rear with a grassed area and trees and flower borders. This has facilities for service users to sit in the garden. The home has a shower room downstairs and a bathroom upstairs. The home is located in an area of Hanley with access to some local shops and a 20-minute walk to the main shopping area. The service users can attend a local college and have the opportunity to undertake some activities. The staff employed the home undertake the activities and some trips out with the service users. The aim of the home is to promote the independence of the service users and to support and encourage them to develop their life skills. The current fee level is £325- £339 per week. Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a five-hour period. Discussions were held with several of the residents about their experiences of living at the home. Discussions were also held with the Care Manager and the deputy who was providing the care on the day of the inspection. A sample of resident documentation was looked at as well as an inspection of the medication procedures and the methods for managing residents’ money. A sample of bedrooms was looked at as well as the communal accommodation. Records relating to health and safety were examined including fire safety records, and records of water temperatures. Menus were examined. The inspection also included looking at the recruitment and selection procedures and the training records. What the service does well: All the residents spoken to stated they liked living at the home and that they got on well with the staff. They felt that the staff listened to them and if they had a problem the staff were approachable and would sort out their problems. Residents were happy with the accommodation and residents said they liked their bedrooms. Bedrooms were well personalised with residents’ belongings. One resident was very proud of her bedroom that had recently been decorated and she said she had chosen the colour. Staff were encouraged to make decisions about their lives and residents stated that they could chose whether to spend time in their rooms or in the communal areas. Residents had the choice to attend college and to take part in activities. Residents and staff developed the menus and residents went with staff to do the food shopping. The home provided excellent opportunities for residents to develop skills and knowledge by attending college. Courses taken included painting and decorating, gardening, art, drama, sewing and jewellery making. The home had robust procedures in place to support the residents to manage their money and to record expenditure. Residents’ personal care needs were being met with staff providing the appropriate level of support. Residents felt their privacy was respected. Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There were a number of areas that the home needed to address to meet the required standards. Whilst the home had developed individual support plans identifying the needs of residents, as the documentation was not dated it could not confirm that plans were being regularly reviewed. The home also needed to more active in pursuing reassessments when these were needed. The residents have good opportunities to undertake educational courses but the home needs to make sure that residents have access and support to undertake a range of social and leisure activities. The home also needs to make sure that residents are offered a sweet at lunchtime. The home needed to ensure that all staff received appropriate training in medication prior to being responsible for its administration. This has been outstanding since the last inspection and must be addressed to ensure that residents are protected. In addition the home needs to ensure that residents that self medicate keep the medication securely. The home accommodation was generally well maintained and satisfactorily decorated but the bathroom should be decorated to improve the accommodation and the home would benefit from having a new shower fitted. The home’s recruitment and selection procedures were ensuring that a CRB and two references were provided but there was no documentation on file to confirm staff’s identities. The home needs to further develop its systems to review the quality of the service. The homes’ health and safety procedures were in the main protecting the residents but the home needs to ensure all staff are up to date with all aspects of their health and safety training and that the action plan to ensure that the home meets the fire service requirements is completed. Please contact the provider for advice of actions taken in response to this Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shamu DS0000064026.V296880.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 Shamu DS0000064026.V296880.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): 2,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there were no pre admission assessments on file there was evidence that the needs of residents had been identified through subsequent internal assessments. Residents were provided with a contract that identified their rights and responsibilities. EVIDENCE: Sampling of residents care files did not show the presence of any preadmission assessments but the home had undertaken internal assessments that identified the care needs and background of the residents. These formed the basis of the support plans. There was evidence from discussion with the Care Manager that at least one resident had been awaiting a reassessment of their needs by the local authority for some time. Copies of internal contracts were on file. These covered the service provided including the accommodation provided room that a resident would occupy. The resident had signed these contacts. Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s care planning processes were identifying the needs of the residents but was not clearly showing that reviews were being completed regularly. Residents were supported to take acceptable risks and were not subject to unnecessary restrictions. The home promoted residents’ choice and participation enabling them to make decisions about their lives based on their preferences. EVIDENCE: Sampling of residents care files showed that the home had developed support plans that identified the needs of the residents and showed staff the actions to take to meet the needs of the residents. These covered the main areas including health and personal care, occupational and educational needs and family contacts. Whilst there was some evidence of review with residents these documents were not dated and therefore it could not be ascertained if reviews were taking place regularly. Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 11 The home had developed individual risk assessments and these covered areas such as accessing the community, bathing, use of the kitchen, scalding and financial management. These had been reviewed and there was evidence that risk assessments were removed when no longer applicable. Residents stated that they were involved in making choices and decisions over their lives. One resident stated that she could go to college but had chosen not to, she had chosen the colour of her room when it was decorated and went shopping for clothes. On the day of the inspection she had chosen to go out for lunch. Residents were able to decide if they wanted to join in with activities, when to spend time in their rooms or in the communal areas and when to get up and go to bed. Residents had also decided together where to go on holiday. Residents were supported by staff to manage their money and the level of support was documented in the files. Residents were able to choose how to spend their money. All residents participated in aspects of running the home. The said that they met to decide on the menus for the week and went with staff to get the weekly food shopping. Residents helped to kept the home clean and tidy by working with staff to clean and tidy their bedrooms and to vacuum the lounge and dining room. There does however remain scope for further involvement and participation. Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides residents with good opportunities to develop their knowledge through college attendance and does provide some social and leisure activities although this needs to be further developed. Residents are benefiting from flexible routines enabling residents to make decisions about their everyday lives. The home was supporting residents to maintain relationships with friends and family. Whilst the residents liked the meals provided and they were involved in planning the menus the home needs to ensure that a sweet is offered at lunchtime. EVIDENCE: The residents have the opportunity to attend college and most take this up with several attending at least three times a week. They take part in a range of courses including art and drama, music, sewing, jewellery making and painting and decorating. The residents regularly access the community attending community health resources as well as regularly going shopping. One resident attends church. Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 13 The home does support residents to participate in some social and leisure activities but since the last inspection the home has lost its part time activity staff member and this has not been replaced. Within the home residents watch TV, DVDs and videos and listen to music. The home also arranges beauty evenings where residents can have pedicures, hairdressing and make up applied. Residents also stated that they sometimes did baking. The home organises some trips out and they have been to Treatham gardens and to Manchester airport. Residents go to the pub and to occasionally to discos. There is a need for the home to support residents to undertake more activities to provide them with a more full and varied lifestyle. The residents are due to go on holiday, which they fund themselves. The home has shared access to a people carrier. The residents pay towards the running costs. The routines in the home were flexible with residents able to make choices over how they spent their time. Residents get up and go to bed when they choose depending on their individually agreed schedules. They can access the lounge and dining room and their bedrooms whenever they want. Access to the kitchen is restricted due to the risk posed to some residents. Most residents have drink-making facilities in their bedrooms and therefore can have drinks when they want. Visitors are welcomed to the home. Residents stated that they went to visit their family and went out with friends. The residents liked the meals provided and met with staff to decide the week’s menus. The food records showed a varied menu being provided and there was evidence of fresh fruit being provided. The home’s records showed that all residents tended to eat the same but residents stated that if they did not like a meal they could have an alternative from whatever food was in the home. The main meal during the week was in the early evening and a light lunch was served around midday. The home did need to ensure that a sweet was offered at lunchtime. Those at college for the day took a packed lunch. The home takes account of the dietary needs of the residents and works to provide a healthy low fat diet. Residents stated that they were involved in meal preparation , doing such tasks as laying the table and washing up. None of the residents needed help with eating. Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided residents with the necessary support to ensure that their personal care needs were being met. The residents’ healthcare needs were in the main being met with residents having medical reviews. Whilst the records showed that the residents were receiving the correct medication the home must ensure that all staff are appropriately trained and that medication is securely kept for those that self-medicate. EVIDENCE: The records and the discussions with residents confirmed that the home was meeting the personal care needs of the residents. All residents were supported/ encouraged to shower or bath daily and observation showed them to be satisfactorily groomed with clean and trimmed nails and clean and styled hair. Residents stated that the staff provided the necessary support in these areas. Residents stated that they had eye checks and dental checks. All residents had a key worker and residents knew who their key worker was. The home supported residents to access health services both primary and through the hospital. A diabetic nurse spoken to previously stated that the company supported the residents well to manage their condition and supported them to attend appointments. The residents were supported to access psychiatric Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 15 services. Staff demonstrated that they were alert to changes in residents’ conditions as a potential indicator of deteriorating mental wellbeing. The home had appropriate storage facilities for medication. The records examined showed residents were receiving the correct medication and there were no gaps in the administration sheets. The home does need to ensure that all staff receive comprehensive training prior to administering medication. This is especially important when staff are working alone. One resident was selfmedicating and an assessment had been completed. Discussions with the resident confirmed that they were aware of how and when to take the medication and that staff checked that it was being taken correctly. However the medication was not being kept securely. Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents knew the complaints procedure and they felt that the staff listened to any concerns and would act upon them. The home’s procedures and the training of staff was increasing the protection for the residents. EVIDENCE: Residents stated that they knew how to complain and that they had the opportunity to raise issues individually and in resident meetings. They felt that staff listened to them and would act on any concerns they raised. The home’s complaints procedure was displayed in the hallway. No complaints had been received by the home. The company had a programme for training in adult protection issues. A staff member spoken to was able to describe signs and symptoms of abuse and was aware of how to respond to any possible issues of abuse. The home had procedures in place to manage and record residents’ expenditure. Checking of this procedure showed that residents’ expenditure was appropriately recorded and was supported by receipts. The level of support residents needed to manage their finances was recorded. Residents went to the bank to withdraw personal money and they went to pay their fees. Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 17 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): 24,26,27,28,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s accommodation was suitable to meet the needs of the residents although the bathroom did need decorating and the home would benefit from new shower facilities. The residents benefited from bedroom accommodation that afforded them privacy and that they could make their own. The residents benefited from a home that was clean and tidy and where procedures were in place to control the spread of infections. EVIDENCE: The home was in keeping with the surrounding properties. It was satisfactory to meet the needs of the residents. The home was satisfactorily maintained and homely throughout. Since the last inspection one bedroom, the dining room and the hall and stairs had been decorated. The occupant of the room that had been decorated was extremely pleased and confirmed that she had chosen the colours for it. All bedrooms were for single occupancy and residents had made them their own with their own possessions. Bedrooms were of varying size with several being very large. The occupants of two bedrooms had bought built-in furniture. The bedrooms provided adequate storage facilities and all were lockable. Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 18 The home had suitable communal areas having a lounge and dining room. Both were suitably decorated in a domestic style. The home had sufficient bathing facilities having a bathroom upstairs and a shower room downstairs. Both were lockable. The bathroom did need decorating and the home would benefit from new shower facilities. The home was clean and tidy throughout and the home had cleaning schedules in place to control the spread of infection. The home shared a laundry with the home next door. The home checked the temperatures of water to control the risk of the legionella bacteria. Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s staffing levels were adequate to meet the personal care and healthcare needs of the residents but additional hours were needed to develop the opportunities for activities for the residents. The home’s recruitment and selection procedures ensured that the home undertook pre employment checks but needed to include the confirmation of staff’s identity in order to provide residents with a greater level of protection. EVIDENCE: The home had one staff member on duty at all times during the day and evening and one sleep in staff member at night. This level of staff was adequate to meet the basic needs of the residents but only allowed for residents to go out with staff if all the residents went out or the Care Manager was available to provide alternative support within the home. Also since the last inspection the part time activity staff member has moved and has not been replaced. This has meant that care staff now provide all the support for residents to undertake activities in and out of the home. Residents stated that they liked the staff and said they were helpful and listened to them. The staff member spoken to during the inspection was aware of her role and was fully aware of the residents’ needs. The home had two staff close to completing NVQ level 2 and the deputy who works occasional Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 20 shifts at the home had NVQ 3 and is awaiting the outcome of her Registered Managers Award. Three care staff were undertaking LDAF courses. All staff undertook induction training. The home maintained training records for all staff and the inspection of a sample of these files showed that staff had completed most of the Health and safety training and had received training in adult protection. The home’s recruitment and selection training ensured that pre employment checks were completed including a CRB checks and two references. There was no confirmation of staff’s identity on file. The Care Manager provided staff with support to undertake their role. Staff meetings were held but staff would benefit from these being held more often. The staff also received individual supervision. Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 21 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 outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was being satisfactorily led but residents would benefit from the home having a more comprehensive system for the review of quality that included residents’ views. Whilst the home was, in most areas, providing residents with a safe environment it needed to ensure every staff member had received the required Health and Safety training and that the actions required by the fire service were completed. EVIDENCE: The Care Manager had the skills, knowledge and experience to effectively manage the home. She had completed the Registered Manager Award. The home had some quality systems in place including the auditing of a range of issues on a monthly basis. This included Health and Safety issues, care documents and cleanliness and hygiene. The home needed to improve the Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 22 system by including the views of residents and by assessing how far the home was meeting the aims and objectives set out in the Statement of Purpose and identifying how the service could be developed. The home had Health and Safety procedures in place and most staff had received the necessary Health and Safety training although some staff’s training in moving and handling needed to be updated. The home was undertaking the necessary fire checks and had regular fire drills. The home was in the process of developing an evacuation plan and there were some areas of work that needed to be completed to meet the fire regulations. The home had an action plan in place to achieve this. The home had current gas safety and electrical installation certificates and PAT testing was being undertaken. The home checked the temperatures of the water. The home had the necessary insurance cover. Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 23 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 2 X Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 24 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 YA6 YA2 Regulation 14(2)&15(2) Requirement Timescale for action 15/07/06 2. YA14 YA33 3. 4. 5. YA17 YA19 YA20 6. 7. 8. 9. 10. Shamu YA20 YA24 YA34 YA39 To ensure that the records clearly confirm when support plans are reviewed and reassessments actively pursued when needed. 16(2)(m)&(n)& To ensure there is adequate 18(1) staffing to provide residents with a range of activities both in and out of the home based on their choice. 16(2)(i) To ensure that residents are always offered a sweet at lunchtime. 13(1)(b) To ensure that all residents have access to dental care 13(2) &18(1) To ensure that all staff receive appropriate training in medication prior to administering medication (Previous timescale not met) 13(2) To ensure that medication for those that self medicate is kept securely. 23(2)(d) To decorate the bathroom. 19 24 18(1)(i) To ensure that proof of identity is kept on file. To further develop the system for the review of quality. To ensure that all staff have DS0000064026.V296880.R01.S.doc 01/08/06 14/06/06 01/08/06 01/07/06 14/06/06 01/10/06 01/07/06 01/09/06 01/09/06 Page 25 YA42 Version 5.2 received the necessary Health and safety training 12. YA42 23(4) To ensure that the action plan for compliance with fire safety regulations is completed 30/06/06 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. 3. Refer to Standard YA8 YA27 YA36 YA35 YA6 Good Practice Recommendations To look at ways of increasing resident participation in aspects of running the home. To provide more suitable shower facilities To increase the regularity of staff meetings. To develop person centred planning. Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Shamu DS0000064026.V296880.R01.S.doc Version 5.2 Page 27 - 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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