Inspection on 29/06/07 for Shassab

This inspection was carried out on 29th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shassab 08/05/08

Shassab 19/06/06

Shassab 13/02/06

Shassab 23/08/05

Shassab 07/12/04

Shassab 01/06/04

Similar services:

Sunny Bank (P.R.S.) Ltd

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

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

CARE HOME ADULTS 18-65 Shassab 144 Manchester Road Chorlton Manchester M16 0DZ Lead Inspector Joe Kenny Unannounced Inspection 29 June 2007 10:00 Shassab DS0000055957.V338734.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 DS0000055957.V338734.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 DS0000055957.V338734.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shassab Address 144 Manchester Road Chorlton Manchester M16 0DZ 0161 860 4596 F/P 0161 860 4596 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 DS0000055957.V338734.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). 30th August 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 concreted outdoor area to 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. Shassab DS0000055957.V338734.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out unannounced on the 29 June 2007. The inspection looked at information provided to the Commission since the last inspection and information provided by the provider prior to this site visit. This included an Annual Quality Assurance Assessment, comment cards and notifications by the home since the last inspection. During the visit time was spent observing staff interaction, talking to people who live at the home and discussions with the manager and staff. Documents and files relating to people and how the home is run were also seen and a tour of the building and grounds was made. What the service does well: What has improved since the last inspection? The home regularly reviews the support it provides people especially around the areas of personal and healthcare. The home continued to provide evidence that people were supported on matters relating to their finances. Medication was held securely and was in order. Shassab DS0000055957.V338734.R01.S.doc Version 5.2 Page 6 What they could do better: 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. The summary of this inspection report can be made available in other formats on request. Shassab DS0000055957.V338734.R01.S.doc Version 5.2 Page 7 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 DS0000055957.V338734.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information provided to people about the home needs reviewing as it is potentially misleading. EVIDENCE: The manager gave a detailed account of steps taken to support people considering moving to the home. An assessment of needs is forwarded to the home by the person’s social worker. The manager stated the he will take the opportunity to visit the person before admission to gather information from the person and family members. The person considering moving is invited to visit the home, have a meal and meet other people before making the decision to move there. Following admission a review is conducted after the first six weeks to assess how the person is settling in, if their needs are being met and to determine if they wish to remain at the home. The most recent admission to the home was as an emergency for respite care. Following the person’s discharge it was evident that the home was not in receipt of the necessary information to support this person. The home must Shassab DS0000055957.V338734.R01.S.doc Version 5.2 Page 9 ensure it follows its admission procedures outlined above, to ensure it is in receipt of all necessary information prior to offering a service. Four comment cards were received from people who used the service. Three were completed by people living at the home and one relative completed the form on person’s behalf. All indicated they were consulted about moving to the home except one who stated they were not asked about moving there. Two comments were: ‘…best option at time, I am please with the service’ and ‘The manager and social worker very helpful’ The descriptive picture, as illustrated on the homes brochure, is not an accurate reflection of the building and the brochure should be reviewed. Shassab DS0000055957.V338734.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. 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. Plans of support failed to evidence people were supported to develop independent lifestyles. EVIDENCE: On admission the needs of individuals are assessed and this information along with the homes own assessment assists in developing care and support plans. Plans are drawn up to address personal, health, mental health, nutritional, cultural, religious and social needs. Staff contribute to the support plans on a daily basis to record personal care and health issues. Reviews also indicated that areas of personal care and health are monitored and evaluated. There is a need to ensure the cultural, dietary, social, leisure and religious needs are referred to in daily records and review of support provided. Shassab DS0000055957.V338734.R01.S.doc Version 5.2 Page 11 Care plans must evidence how people are supported on aspects of mental health care and how staff support people. Greater access to health care professionals and resources such as occupational therapists should be accessed by the home to support care planning and assist staff when supporting people. There was little evidence of how people take responsibility for the day to day living arrangements in the home to develop their independence and how they access public services. The comment cards completed by people using the service were positive, all stating that they knew who to speak to and knew how to make a complaint. Comments were as follows: Treat people ‘in a polite manner and respectful’ ‘fantastic service for people with a disability and mental illness’ ‘it is a nice home and friendly’ ‘staff is helpful and always at hand to help if needed’ Shassab DS0000055957.V338734.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. 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. EVIDENCE: Staff confirmed that people are free to choose when they get up and when they go to bed. Each person had a programme of support that included personal and healthcare tasks. One person living at the home continues to access day care services three days per week and is supported by staff and the manager to attend day care. Relatives are encouraged to maintain contact and be involved in people’s care, with some people going on home visits at weekends. Shassab DS0000055957.V338734.R01.S.doc Version 5.2 Page 13 During discussions, staff stated people were assisted to access local resources and go on walks and trips out. Where people are supported on such events a record should be maintained on their file to evidence this. Previous reports required the home to evidence that people had the opportunity to access a wide range of social and leisure activities. On the day of the inspection, activities such as personal exercise and colouring books, ‘Super Jumbo Book’, were presented as activities recently undertaken by people. Discussions were held in relation to the age appropriateness of such activities. The manager was advised to liaise with professionals such as occupational therapists on more appropriate activities. Other activities, such as board and tabletop games were available to people. During the course of the inspection people were observed to move about the home without direct involvement of staff to support them on engaging activities. Weekly prayer meetings, ‘Zikar’ and events such as ‘Mela’, a celebration, social gathering, are held in house during the week. Staff stated people could take their meals when they choose. One person was seen to eat from a pre plated meal placed on the dining table. No condiments or drink were available to the person. Meal times did not appear to be held as a social event. Food stocks in the kitchen were very limited for the six people resident in the home. The manager did however, indicate the weekly shopping for the home would be carried out on the day following this visit. Food containers were not clean and should be replaced. The contents of the containers should be appropriately stock rotated. Large bins are used to store flower and rice. When the lid was removed from one container, flying ants were on the rim of the bin. Such storage arrangements must be regularly checked and cleaned to ensure safe storage. All food products stored in the fridge must be labelled and dated to ensure safe storage and use. The fire blanket next to the cooker was hung upside down and may restrict appropriate access when needed. There were limited plates, cups and cutlery in the kitchen area. The manager is advised to monitor the above observations and take appropriate action to address shortfalls. Shassab DS0000055957.V338734.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. 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 general healthcare. EVIDENCE: There were six persons residing in the home at the time of the visit. People’s personal and general health care needs 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. At the time of the inspection medication procedures for the month had started. The blister pack and medication records were found to be in order and correct. Medication is held securely and administered by senior staff and for the greater part by the registered manager. The home also maintained a record of medication received and returned for disposal to the pharmacist. Shassab DS0000055957.V338734.R01.S.doc Version 5.2 Page 15 District nurses support people when needed and one person was being supported at the time of the inspection. The district nurse stated she was confident in the ongoing support offered by staff to the person she visited. Each person is registered with a general practitioner of their choice who will visit the home on request. The home has access to appropriate equipment to support people with a physical disability, including a hoist and adapted motorised wheel chair. The manager stated staff had received instruction in the use of such equipment. People’s mental health needs were assessed on admission to the home but there was no evidence that there was ongoing monitoring of mental health needs or plans to effectively meet these needs. Shassab DS0000055957.V338734.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures in the home ensure people’s views are listened to and that people are protected from financial abuse. EVIDENCE: The home’s complaint procedure sets out how people can raise their concerns about the service they receive and provides people with contact details for local social services departments and the Commission for Social Care Inspection (CSCI). The manager stated no complaints had been received by the home since the last inspection. The home keeps a register of complaints it may receive. The last recorded complaint dated back to 2003. No complaints had been received by the Commission in the same period. 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. No issues had been referred under safeguarding procedures. The finances of people were examined as part of the inspection and records and amounts of cash were examined and found to be in order. When a transaction takes place, receipts are obtained and held with the records of people’s finances. Shassab DS0000055957.V338734.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Standards of decorating and cleanliness in the home were poor and the environment was not homely. EVIDENCE: As previously stated the descriptive picture, as illustrated on the homes brochure, is not an accurate reflection of the building. Some facilities in the home are very cramped and of a poor standard. This included toilets and bathing facilities. The laundry and sluice facilities must be kept locked and secure as chemical hazard cleaning products are stored within the facility. On the day of the inspection some rodent poison was accessible in the area and a light fitting had been removed leaving wiring hanging. It was unclear as to whether the electricity to the fitting had been isolated. A section of the shower unit on the upper floor had been removed and wiring left hanging loose. The switch to the shower unit on the outside of the facility indicated that the system was live when switched on. The manager was Shassab DS0000055957.V338734.R01.S.doc Version 5.2 Page 18 advised to request an electrical engineer to attend to these two areas at the time of the inspection. Work was in progress to clear and redecorate a room, which had suffered smoke damage. As you approach this room, a window on the corridor looks directly into a person’s bedroom. No privacy curtains were in place, this failed to offer appropriate privacy and dignity to the person occupying this room. The external vent from the boiler in the kitchen is located at waist height and in close proximity to the rear door. The vent is excessively hot to touch and presented as a risk to people accessing the external grounds who may come in contact with it. A safety cage should be fitted over the vent to restrict access. Outside the door mops were placed on the concrete, one used for toilets and one used for the kitchen area. Neither was labelled as to which area they should be used in, the manager was advised to ensure they are labelled and stored appropriately. The boundary fence to the neighbouring property was damaged and required repairing. Internally there was evidence of work being carried out to decorate the hall and doors in the foyer. This work was being carried out whilst people living in the home moved about and were coming in contact with wet painted surfaces. Standards of decorating in bedrooms varied and in some rooms there was little evidence of personal belongings. One person is cared for in their bedroom. A number of information sheets on care, personal hygiene and moving and handling procedures were posted to the walls. The manager was advised to remove the documents and hold them within a folder in the person’s room for staff to refer to. Prior to supporting the person staff should be familiar with such information and procedures. The posting of this information failed to give a homely, individual feel to the person’s room. The manager was also advised to review the position of cleaning charts posted on bedroom doors and other facilities such as toilets and bathrooms. The bathroom on the ground floor required upgrading and decorating, to improve the appearance of the facility. The designated smoking area is very small and would benefit from a programme of cleaning and decorating. The quality of cleaning, maintenance and decorating arrangements at home continue to be of a basic standard requiring regular attention. This observation has been made on all previous inspections to provide people with a well maintained, decorated and homely environment. Shassab DS0000055957.V338734.R01.S.doc Version 5.2 Page 19 Throughout the course of the inspection it was noted that all internal doors were wedged open. The manager was advised to monitor and risk assess this practice and to address this in the home’s fire risk assessment. Shassab DS0000055957.V338734.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff’s lack of knowledge of mental health issues means the peoples needs are not fully met. EVIDENCE: Staff as part of their duties have responsibility for domestic and catering arrangements in the home. The staff files contained little evidence of training provided to staff on supporting people with mental heath care needs. The manager is advised to retain on staff files, detailed information on training achieved and planned for each staff member. The information is necessary in order for the home to evidence how it supports people to meet their assessed personal and social interests. This information should be retained in an easily accessed filing system. Shassab DS0000055957.V338734.R01.S.doc Version 5.2 Page 21 The manager stated the staff were in the process of working towards NVQ Level 2. The manager and deputy manager have completed NVQ level 4 and the Registered Mangers Award. With the exception of three staff members the remaining personnel are all family members. The manager is required to evidence that supervision is provided to all staff. The manager stated he met staff on a daily basis to discuss issues relating to care and work undertaken by staff. A more formal system should be established to offer staff one to one supervision on a 2 to 3 monthly basis. Records relating to Criminal Record Bureau (CRB) checks were examined on the day and the manager provided a list of staff who had completed CRB checks. This information was checked against staff files to confirm such checks had been carried out. One member of staff had a POVA First clearance and was awaiting a completed CRB check. The rotas for each week are drawn up by the manager with staff rostered in blocks of two hour periods. The hours for week ending 30 June indicated 339 hours were used and this included one member of staff on waking night duty. In the event of an additional person being required on nights, the manager stated that a person would be available, on sleep in duty in the office, on call if required. The manager and deputy manager are responsible for recruitment of staff and induction procedures. These were found to be appropriate. Shassab DS0000055957.V338734.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management and administration procedures required developing to ensure the views of people are taken into account in the running of the home. EVIDENCE: The registered manager has undertaken the NVQ level 4 in Care and Management. The home continues to by managed and staffed mainly by family members. The manager and staff stated they continue to seek people’s views about the care they received. This required further developing to ensure support is appropriate to the needs and abilities of people. Although staff indicated people are involved in day-to-day arrangements for the conduct of the home, there was no recorded evidence of this. Shassab DS0000055957.V338734.R01.S.doc Version 5.2 Page 23 There is a need to provide greater evidence of people’s involvement in meal and menu arrangements, with mealtime as an opportunity for social interaction during the day. The home is advised to review and hold regular training sessions on fire safety arrangements in light of the recent fire incident in the home. The home is also advised to ensure it addresses the areas of none compliance identified by officers in their reports dated the 1 July 2007. Issues relating to safety identified in the premises section of this report required addressing to ensure people are safe. The last internal quality review of the service was conducted a year ago and the home is advised to conduct at least an annual quality assurance programme that seeks the views of people and others that come into contact with the home. The home is advised to use the information to develop a plan of action setting out how they are going to raise the standards of the service people receive. Records relating to fire tests and checks were in order. The manager was advised to request staff to sign the fire register in person when they are involved in a fire drill. Shassab DS0000055957.V338734.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 2 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Shassab DS0000055957.V338734.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14 Requirement Admission procedures must be followed to ensure all necessary information is received prior to offering a service. Care plans must evidence how people are supported on aspects of mental health care and how staff support people. People’s need for support to access community facilities must be recorded in their care plan. Appropriate action must be taken to ensure ample provisions are available at all times in the kitchen. Food and powder containers must be replaced and the contents of the containers should be appropriately stock rotated. All food products stored in the fridge must be labelled and dated to ensure safe storage and use. Action must be taken to address a significant number of issues relating to health and safety and the environment as detailed in the Premises section of this report to ensure the safety of people living at the home. DS0000055957.V338734.R01.S.doc Timescale for action 24/08/07 2 YA6 15 24/08/07 3 4 YA12 YA24 16 23 24/08/07 24/08/07 5 YA24 23 24/08/07 Shassab Version 5.2 Page 26 6 YA35 18 Staff must receive training in meeting all the assessed needs of people living at the home. 24/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 8 Refer to Standard YA6 YA6 YA24 YA24 YA24 YA24 YA35 YA39 Good Practice Recommendations The manager is advised to liaise with professionals such as occupational therapists on more age appropriate activities for people living in the home. The home is advise to review meal time arangements for people, so that meal times are held as a social event The home is advised to ensure a wider range of plates, cups and cutlery is available in the kitchen. The fire blanket next to the cooker should be hung correctly to ensure it is accessible at all times when needed. The descriptive picture of the home, as illustrated on the homes brochure, should be ammended as it is not an accurate reflection of the building. The manager is advised to review the position of cleaning charts posted on people bedroom doors and other facilities such as toilets and bathrooms. Regular training sessions on fire safety should be provided to staff. 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 manager was advised to request staff to sign the fire register in person when they are involved in a fire drill. 8 YA37 Shassab DS0000055957.V338734.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North West Regional Office 9th Floor Oakland House Talbot Road, Old Trafford Manchester M16 0PQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shassab DS0000055957.V338734.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!