CARE HOME ADULTS 18-65
Shassab, 144 Manchester Road, Chorlton, Manchester 144 Manchester Road Chorlton Manchester M16 0DZ Lead Inspector
Steve O`Connor Key Unannounced Inspection 19th June 2006 1:30
Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.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 Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.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. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Shassab, 144 Manchester Road, Chorlton, Manchester 144 Manchester Road Chorlton Manchester M16 0DZ 0161 860 4596 0161 860 4596 Address 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) Mr Mohammad Iqbal Mr Mohammad Iqbal Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7), Old age, not falling within any of places other category (1) Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. 6. The home accommodates a maximum of 7 service users, aged 18 - 64 years, whose primary need for care arises from mental disorder (excluding learning disability and dementia). The care home provides a separate room where service users can meet visitors in private. All service users are offered the option of a single bedroom. (Service users share bedrooms only where two service users choose to share and have been offered two rooms to use). Minimum staffing levels will be maintained in accordance with the Residential Forum guidelines `Care Staffing in Care Homes for Younger Adults`and service users` assessed levels of need. The service should, at all times,employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. One named service user whose primary need for care and accommodation is old age (OP) is accommodated. If the service user leaves the home the registration will revert to Mental Disorder (18 to 65 years of age, excluding learning disability and dementia). 13th February 2006 Date of last inspection Brief Description of the Service: Shassab is a residential care home providing 24-hour personal care and accommodation for 8 adults with mental health problems and physical disabilities. The service specialises in culturally appropriate care of Asian people. The home is situated on the edge of Chorlton, South Manchester, close to local amenities and public transport routes. It is sited on a residential street and is of the same size and style as other houses surrounding it. It has a small car park to the front and a lawned garden at the rear. Bedroom accommodation is on the ground and first floors. There are 6 single and one double bedroom with hand washbasins. The home has access for people who require wheelchairs for mobility. The communal space is situated on the ground floor along with kitchen and laundry facilities. Information about the home is available on request and via the CSCI Web site. The charges for the home are £343.24 per week. The home provided the Commission with the required information in April 2006. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the end of the last inspection in February 2006. This information includes a pre-inspection questionnaire, completed by the home and submitted in April 2006, an action plan submitted in response to the last inspection report and an unannounced site visit to the home on the 19th June 2006. During the site visit time was spent talking to people who live at the home, the deputy manager and registered manager. Documents and files relating to people and how the home is run were also seen and a tour of the building was made. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work the CSCI needs to do with the home. Although the home had made progress in making the changes needed to meet the required standards, there were several areas that had not been addressed for the last two inspection reports going back to August 2005. These are highlighted in the ‘What the home could do better’ section of the summary. The home were asked to provide the CSCI with a detailed plan of action on how, and when they were going to put these areas right. What the service does well:
The home provides accommodation and support for Asian people and aims to provide a lifestyle which satisfies their cultural and religious needs. An important part of this is speaking to people in the language they prefer. This includes Punjabi, Gujarat, Hindi, Peshawar and English. The majority of the staff team are multi-lingual that allows people to express themselves fully. Having the choice to practice your own faith and religion is another area that the home sees as an important part of a persons’ life. People can choose and be supported to attend the local mosque or to pray in the privacy of their own room. Every Thursday the home hosts a Zikar where people and staff from the home and the local community come together to share in prayers, songs and food. The home also supports a person to attend a local women only Friday prayers meeting (Juma). An important part of the home’s aims is to keep peoples’ general and mental health stable so that they can continue to be a part of their community. No one living at the home has had to be admitted to hospital due any deterioration in their mental health since coming to stay at the home. One person who has a very high level of healthcare needs and has had to have several hospital stays
Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 6 due to these problems was seen spending time with other people in the lounge having their meal. They had regained weight and were being supported well by the staff and from visiting health services. The home has continued to support and encourage people to maintain family links and relationships. Families and friends are encouraged to visit people at home and will often take part in meals and religious events. Several people still visit their families on regular occasions. What has improved since the last inspection? What they could do better:
The home states in its Statement of Purpose that its aim is to encourage people to be as independent as they can, to give people choices that affect their lives and to promote a fulfilling life providing, amongst other things, a range of leisure and recreational activities. However, an area of work that the CSCI has raised on several occasions with the home over the previous inspections is that they are not able to clearly show that the home has offered people the opportunities as they claim is their aim in the Statement of Purpose. The home must make sure that the aims of the home relating to, accessing a wide range of social and leisure activities, access to public services and lifelong learning and taking on responsibilities within the home are fully reflected and evidenced in peoples care plans, care plan reviews, daily programme and daily recording.
Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 7 An important area of the home’s responsibility to people is that if the home helps people to manage their money then the home must make sure that all records of spending and receipts are regular checked to make sure that everything is accurate. Although there has been some improvement in how the home does record peoples’ spending it still does not have a proper way to check. The home must introduce a system whereby the manager, and someone from outside the home, does these checks. The home supports people who can be very vulnerable. To try to make sure that the staff employed by the home are safe to work with such people then every member of staff should have a Criminal Records Bureau check to see if they shouldn’t work with vulnerable people. Although the home has managed to improve the numbers of staff with these checks they have not made sure that all the staff have them. This problem was raised at the last inspection report and has still not been resolved. People depend on staff to have the skills, knowledge and understanding to be able to offer them the right help. Staff should receive a range of training to provide them with those skills. The last inspection report highlighted that the recording of staff training was unclear and could not prove that staff had been properly trained. The home was told to check all the staff training records and find out what training and refresher training they needed. Although the manager stated that they had done this they could not find the documentation and so were told to do it again. 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. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.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 Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home gathers the information it requires to identify peoples’ needs before they come to live at the home. EVIDENCE: Prior to people coming to live at the home the purchasing authority provide either a Care Management or Care Programme Approach (CPA) assessment. The home will undertake its own assessment and this includes visiting the person and their carers and visits to the home. The in-house assessment is then further developed over the first few weeks of a person’s stay to ensure that all their needs are identified. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. On the whole peoples’ assessed and changing needs have been identified. Hazards that people may experience have been identified and support provided to minimize those risks. People are encouraged to make the choices and decisions that affect their day-to-day lives. EVIDENCE: Each person has their own care plan that sets out their identified needs for personal, health, mental health, nutritional, cultural, religious and social needs. The plans were clear and the home had included more detailed information about the goals the person wanted to achieve and the support required to help them. The majority of the goals identified on peoples’ care plans centred on their personal and healthcare needs. Evidence was seen of regular reviews undertaken by some purchasing authorities of peoples’ care and support and a review by a person’s care manager was in progress during the site visit. The home did undertake their own informal six-month review but this focused on people’s personal and
Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 11 health care. It is recommended that the care plans also focus as much on peoples’ goals that relate to their social, leisure and cultural needs and that these gaols are reviewed on a regular basis depending on the complexity of people’s needs and support package. The home had developed a risk assessment process that looked at those areas of a person’s life that could affect their mood and cause them agitation. Areas that may cause hazards through a persons’ behaviour or because of their environment had been identified and guidance provided on how to help the person cope with those situations. These had been regularly reviewed and updated when required. The home was in the process of introducing a new care planning and review system that would integrate all the information about a person and provide systems for reviews and risk assessments. This will be assessed during the next inspection process. The home tries to encourage people to make choices and take decisions about their life through small day-to-day choices. The clothes people wear, that days meal and the in-house activities they want to take part in are all ways that people can make choices. If there are any restrictions of choice of activity or movement then this was only as a result of known hazards and after risk assessments had been completed. An example of this was in a person agreeing with the home for them to keep his cigarettes. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.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, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was not able to fully show that it had offered people the opportunities to participate in appropriate social, leisure and community based activities as set down in its Statement of Purpose. People are supported to maintain family relationships, daily routines are based on people’s personal needs and the home provides them with a diet that people enjoy. EVIDENCE: Several people were independent in being able to access their community and could participate in local amenities and places of worship. Several people had a daily programme of support that included personal and healthcare tasks and activities that they liked to do. People had recently gone on a day trip to a local attraction and the home stated that more of these events were being planned. One person accessed local specialist day care services. The person’s recent review highlighted all the activities that the person enjoyed. This was not reflected in their care plan. It was again recommended that the home liaise
Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 13 more fully with the day service to establish the person’s programme of activities and to see how they can be incorporated into the person’s daily routines. The previous two inspection reports have highlighted that the Statement of Purpose states that the home aims to offer people opportunities to access a wide range of social and leisure activities, access to public services and lifelong learning and taking on responsibilities within the home. However, the care plans, care plan reviews or the daily recording still does not show clear evidence that people are being offered these opportunities (whether they agree to them or not) to participate in such activities. The home must ensure that the aims of the home are fully reflected and evidenced in people’s care plans, care plan reviews, daily programmes and daily recording. The requirement was reiterated again. The home supports and encourages people to maintain family links and relationships. Families and friends are encouraged to visit people at home and will often take part in meals and religious events. Several people still visit their families on regular occasions. People’s routines appear to revolve around activities such as meal times, group activities and individual choices. Some people can be independent in the community and set their own routines whilst others have a more structured day. Those people who wish to have their own room key and can spend time in others company or on their own, mail is given direct to the person unless support is required and people participate in domestic tasks according to their ability. Restrictions of movement around and out of the house are based on the safety of the individual. People’s food likes and dislikes are recorded in their care plan. Those with specific dietary needs are catered for and the choice of meals is discussed with people on a daily basis. The menu offered is based on people’s religious and cultural needs. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home supports people’s personal and healthcare needs but the medication system’s administering information was not totally accurate and so did not fully ensure that the system was safe. EVIDENCE: People’s personal care and healthcare needs and support were identified in the individual care plan. Additional guidance was provided on how to support a persons’ personal care in the way that they want. The home works alongside general and specialist healthcare providers in supporting and accessing the health services needed. The medication administration system was checked and found that the blister pack system used had changed to a more robust packaging and solved the problems found at the last inspection where the packaging was not secured correctly. The Medication Administration Record (MAR) sheets were recorded accurately and all deliveries and returns had been recorded. The only concern found was where a person’s medication had contradictory administering guidance on the packing. One had stated a morning dose and
Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 15 the other an evening dose. The exact administering instructions for medication must be clarified and the accurate information recorded on the MAR sheets. The medication that required cold storage was now kept locked in a separate box in the fridge and met the requirement made at the last inspection. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had the systems in place to allow people to express their complaints. However, it does not have all the procedures and practices in place to ensure that people are fully protected from financial abuse. EVIDENCE: The home has a complaint procedure setting out how people can raise their concerns and what other organisations, including the CSCI, can be contacted to raise complaints and concerns. The procedure was available in written form and had been discussed during the informal ‘chat sessions’. The home had received no formal complaints since the last inspection. The home had adopted the Manchester Multi-Agency Adult Protection Policy and Procedures as its own operational procedures. Staff had been provided with awareness training and information on the procedures. The previous inspection report required the home to make several changes to the way it recorded how it managed people’s money. This included accurate recording of actual amounts spent, obtaining receipts for all spending and not keeping large amounts of people’s cash on the premises. These changes had taken place. The home was also required to develop a clear monitoring and auditing system for the management of people’s personal finances that the home controls. The
Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 17 policy had been reviewed and included the procedure for recording transactions it did not include the monitoring and auditing system as was required. The requirement was reiterated again. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected 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 is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and a safe environment for people to live in. EVIDENCE: The previous inspection report required the home to provide the staff team with updated infection control training due to the vulnerability of some of the people they support. This had been actioned and the requirement was met. The laundry and sluice facilities are provided in a separate room and have the required programmes to deal with soiled washing. The home was generally clean in all areas. The issue of the quality of the maintenance, decoration, furniture and fittings of the home has been raised with the registered provider on several occasions over the past inspections. The home has responded to a large number of concerns raised through an Environmental Health Inspector visit in May 2005 and had provided the CSCI with a programme of decoration for those areas of the house that were looking poorly maintained and decorated. This is an ongoing issue for the home to
Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 19 make sure that it provides people with a well maintained, decorated and homely environment. At the time of the site visit the home was in the process of refurbishing and remodelling two of the upstairs bedrooms. This was causing some disruption and the need to store items around the house. In addition, the home was waiting on delivery of new furniture for the lounge. It is recommended that the home needs to continue with its programme of decoration, refurbishment and updating worn furniture to provide people with a well maintained, decorated and homely environment to live in. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has not been able to fully show that its staff team have the competence to meet peoples’ needs and that they have the systems in place to ensure that staff are safe to work with vulnerable people. EVIDENCE: The previous report highlighted that staff files did not make it clear whether each staff member had an individual training plan/log and what training they had participated in. The home were required to undertake an audit of all the staff training and develop individual staff training plans that set out what training staff have undertaken, what training was required and when refresher training was needed. The registered manager stated that this had been achieved but could not find the audit. Therefore, the requirement was reiterated. The previous inspection report highlighted how the home had problems with its NVQ training provider and had just found an alternative. It was found that none of the support staff had yet to start the NVQ Level 2 course but the home stated that four staff would be starting in September 2006. It is recommended
Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 21 that the home provide the CSCI with an action plan on how it is going to ensure its staff completed the NVQ level 2. As training records were incomplete and no support staff had any vocational training there was insufficient evidence to show that people are supported by a competent staff team. The home has not needed to recruit any new staff since the last inspection. As the home is a family business several of the staff are a part of the owners family. The previous inspection report highlighted that not all staff had a current Criminal Record Bureau (CRB) disclosure certificates although the application forms were seen. There was still one staff member who did not have a CRB disclosure certificate. The requirement was reiterated. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected 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 is adequate. This judgement has been made using available evidence including a visit to this service. The home has the systems and checks in place to maintain peoples’ health and safety. The registered manager has the qualifications and experience to run the care home. The home does seek peoples’ views on the service they receive but does not develop an action plan from the process. EVIDENCE: The registered manager is also the owner of the home that has been in operation for around 12 years. They have undertaken the NVQ level 4 in Care and Management. They have full responsibility for all decisions affecting the running of the home and implementing the National Minimum Standards. The home does seek peoples’ views through the regular meetings that people have. People are asked if they have any concerns or worries and areas such as meals and activities are raised.
Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 23 The home also asks people and their carers and other professional that come into contact with the home to fill out a questionnaire that looks at the quality of the service. This was last completed in June 2005. What the home has not yet carried out is how it then uses the information it gathers from people to look at how it may provide a better service. It is recommended that the home undertake at least an annual quality assurance programme that seeks the views of people and others that come into contact with the home and from that the home must use that information to develop a plan of action setting out how they are going to raise the standards of the service people receive. The fire log was seen and found that the required checks were being made. The home had undertaken its own fire risk assessment. Evidence was seen that electrical, gas and fire equipment had been annually serviced and environmental/safe work practice risk assessments had been completed. Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43
DS0000055957.V299065.R01.S.doc 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X
Version 5.2 Page 25 Shassab, 144 Manchester Road, Chorlton, Manchester 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 YA12 Regulation 16 Requirement The home must ensure that the aims of the home relating to, accessing a wide range of social and leisure activities, access to public services and lifelong learning and taking on responsibilities within the home are fully reflected and evidenced in peoples care plans, care plan reviews, daily programme and daily recording. (Previous timescale of 01/09/05 and 01/05/06 were not met) 2. YA20 13 The exact administering instructions for medication must be clarified and the accurate information recorded on the MAR sheets. 01/08/06 Timescale for action 01/08/06 3. YA23 13 The Finance policy and 01/08/06 procedure must set out the monitoring and auditing system to be used to ensure that records and peoples funds were accurate. (Previous timescale of 01/09/05 and 01/05/06 were not met)
DS0000055957.V299065.R01.S.doc Version 5.2 Page 26 Shassab, 144 Manchester Road, Chorlton, Manchester 4. YA34 19 5. YA35 19 The home must ensure that all staff have applied and received a CRB disclosure certificate and POVA check before they start employment. (Timescale of 01/03/06 was not met). The home must undertake an audit of all the staff training and develop individual staff training plans that set out what training staff have undertaken, what training was required and when refresher training was needed.(The timescale of 01/05/06 was not met). 30/07/06 30/07/06 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 Refer to Standard YA6 Good Practice Recommendations It is recommended that the care plans focus as much on peoples’ goals that relate to their social, leisure and cultural needs and that these gaols are reviewed on a regular basis depending on the complexity of people’s needs and support package. It is recommended that the home liaise more fully with the day service to establish the persons programme of activities and to see how they can be incorporated into the persons daily routines. It is recommended that the home needs to continue with its programme of decoration, refurbishment and updating worn furniture to provide people with a well maintained, decorated and homely environment to live in. It is recommended that the home provide the CSCI with an action plan on how it is going to ensure its staff completes the NVQ level 2. 2. YA12 3 YA24 4 YA32 Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 27 5 YA39 It is recommended that the home undertake at least an annual quality assurance programme that seeks the views of people and others that come into contact with the home and from that the home must use that information to develop a plan of action setting out how they are going to raise the standards of the service people receive. It is recommended that the home undertake at least an annual quality assurance programme that seeks the views of people and others that come into contact with the home. 6 YA42 Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Shassab, 144 Manchester Road, Chorlton, Manchester DS0000055957.V299065.R01.S.doc Version 5.2 Page 29 - 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!
