Inspection on 08/05/08 for Shassab

This inspection was carried out on 8th May 2008.

CSCI found this care home to be providing an Adequate service.

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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shassab 29/06/07

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 28/09/2008.

CARE HOME ADULTS 18-65 Shassab 144 Manchester Road Chorlton Manchester M16 0DZ Lead Inspector Joe Kenny Unannounced Inspection 8 May 2008 11:30 Shassab DS0000055957.V361167.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.V361167.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.V361167.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.V361167.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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). Old age, not falling within any other category (1) Date of last inspection 29th June 2007 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. 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.V361167.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection was carried out on the 8 May 2008 with follow up visits on the 9 and the 15 May 2008. The registered manager was not present at the time of the visits and the inspection was conducted by a designated family member acting as manager of the service. The home provided the commission with a completed Annual Quality Assurance Assessment (AQAA), self-assessment of how it felt it was meeting national minimum standards, with additional information about the service they provide and staffing information. The inspection also looked at information received by the Commission in relation to the home prior to the site visit. A number of comment cards were forwarded to people living there (one returned) and to staff (two returned) as a further means of seeking their views. The information received is included in this report. During theses visits time was spent in discussion with staff and observations were made of staff and service user interaction. Documents and files relating to service users, staff and the home were examined and a tour of the home and its grounds was undertaken. The Statement of Purpose states the home supports people on faith and cultural issues and needs to be extended to also include social and health care needs. The inspection also focused on protection and safeguarding issues. The outcomes were poor with a need for the home to provide training to staff and review written policies and procedures. What the service does well: The home continues to provide a specialist service for Asian people and aims to provide a level of care, which reflects their cultural and religious needs. This objective is set out in the homes published information about the service it provides. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 6 People are encouraged to maintain contact with their family and local community. This is achieved through contact with local Mosques and day resource services for one service user. Staff supporting people are skilled in speaking to them in their preferred language. What has improved since the last inspection? What they could do better: The home’s illustration on its brochure is not a true representation of the building and could be misleading to people considering moving to the home. Areas relating to engaging people in age appropriate activities and social interaction need to be improved to ensure people have access to resources, which meet their assessed needs and ability. There needs to be evidence that people or a representative acting on their behalf are consulted with to ensure the home is acting in the best interest of people. This specifically related to their finances and primary health care needs. A number of issues relating to the building and grounds raised at the last inspection had not been addressed by the home and are reiterated in this report. Action is necessary to ensure a safe and secure environment is provided. Staff training in areas such as, National Vocational Qualifications, infection control and updated protection procedures also required attention. Written procedures on protection required reviewing as current documents had the potential to misdirect staff on action to be taken. The requirements made at the last inspection that all the staff team had a Criminal Records Bureau check had not been addressed. This is an essential check in making sure that staff are safe to work with vulnerable people. Medication procedures required monitoring to protect people. Finance procedures must evidence that the person acting on their behalf has consulted with them or their representative regarding purchases made. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 7 People supported in care homes do so for a variety of reasons but generally they need help and support to allow them to live as independently and safely as possible. The home and staff must evidence that they understand, what help people need. To do this care plans must clearly set out each persons social, personal and health care needs in sufficient detail, along with the goals that people have and how they are going to support the person. Care plans should be regularly reviewed to see if the care plan is relevant to assessed needs and takes into account any changes in peoples’ needs. 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.V361167.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 DS0000055957.V361167.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information provided to prospective and existing residents must reflect their assessed needs and the registered service category. EVIDENCE: The service continues to be very much run as a family concern, with a number of family members involved in the care and running of the home. The referral process was described by the acting manager. When a referral is identified, the registered manager would visit the person and any relevant people, such as family, and undertake their own pre-admission assessment. The home would also expect a full Community Care Assessment from the purchasing local authority. At the time of the inspection there were five residents accommodated and three vacancies. The home is registered to provide support to people whose primary need for care is mental health, not falling within any other category. No admission had taken place since the last inspection. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 10 Information relating to people at the time of their admission was examined and indicated that three people were referred by mental health teams and two people from learning disability services. This was confirmed in pre admission information provided by the funding authority. The home must ensure the needs of people referred to the home meet the homes registered status to ensure conditions of registration are not breached. The information within the homes brochure was misleading as the illustration of the home is not a true representation of the building and could be misleading to people considering placing or moving to the home. Evidence must be retained the people referred are provided with assurance that the home can meet their assessed needs. On examination of files for the five service users accommodated. No evidence of contracts or statement of terms and condition were seen. Evidence must be retained that people have been provided with a contract which should assure people or their representative that their assessed care needs will be met. One comment card was received from a person who uses the service. The person answered ‘yes’ to the question were you asked if wanted to move to home and commented “I came to visit” before their admission. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. 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. Care plans must evidence that people are supported to live meaningful and independent lifestyles. Care planning systems do not fully reflect peoples’ current and changing needs and goals. EVIDENCE: The home provides a specialist service to Asian people to provide care which reflects their cultural and religious needs. It is advised that plans are expanded to evidence that people are consulted on all aspects of their lifestyle to ensure social and personal interests are also identified and met. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 12 Evidence should also be retained that family representatives and other health professionals are involved to support individuals and staff in the delivery of care. Although plans of care are set out under a number of headings such as personal health, nutrition, cultural and religious needs, there was limited evidence of use of health professionals such as a dietician, community psychiatric service and occupational health therapists in the development and delivery of care. The manager was advised to consult with such professionals especially in the development of age appropriate resources and programmes of support for people to access. Daily records also needed developing to evidence consultation with people regarding daily routines and day to day management of the home. There was little evidence of people being involved in daily issues relating to the home, development of menus, social care programmes and use of internal and external resources. Existing documents should be dated when drawn up or reviewed to assist in monitoring and measuring the effectiveness of intervention. All daily recordings are maintained in one ring binder. The manager was advised to set up individual files to ensure confidentiality of information and data protection are adhered to. One comment card was received from a person who uses the service. The person commented that staff treated them well and listened and acted on what they said. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. 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. Care delivery failed to evidence that lifestyle arrangements fully reflected people’s preferences. EVIDENCE: There is a continuing need for the service to demonstrate that it offers each person a wide range of social and leisure activities which reflect and promote their well being. Staff said people were free to choose when they get up and when they wish to go to bed. People are supported on cultural and religious observances with structured programmes of prayer in the home and access to local mosques. One person is supported to access a day resource service. People are supported to contact and go on home visits. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 14 However, in the wider context of daily life for each person, there was little evidence of consultation, engagement and development of social and leisure programmes to support people’s current health care needs. Board games were available to people in the dining room. The grounds can be accessed for sitting out. The boundary fence required securing and replacing in sections to ensure people were provided with a secure external area. Meal and menu arrangements should evidence that people have been consulted on menu plans and daily preferences at meal times. There did not appear to be a varied menu plan in place and the quantity of provision on site for the five people accommodated was very limited. It was stated that purchases are made when required from local shops. There is a need to ensure ample provisions are onsite to respond to people’s preferences, choices and provision of random snacks. There is also a need to access a greater range of plates and dishes for meal servings. As on previous visits the setting out of tables was minimal at meal times and failed to evidence that meal times were a social event. Observation of meals served over the course of the inspection were that meals were preplated and for two visits the dish served had not changed. All food provisions placed in the fridge for storage should be labelled and dated. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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. Greater evidence should be maintained to evidence that people’s health care needs are being met. The medication administration systems and practices do not fully protect people. EVIDENCE: There is a need to evidence that people receive appropriate support form all health services. This includes advice to staff to enable them to support people appropriately. On examination of people files it was determined the three people were referred by the mental health team and two people by the learning disability team The home must ensure that people’s primary health care need is mental health and that staff are supported and provided with advice on mental health care issues and issues around the Mental Capacity Act. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 16 Procedures relating to medication required reviewing. Medication Administration Records (MAR) should start with a copy of the names of people responsible for its administration and sample signatures of staff. All hand written entries must be signed by the person making the record and should be countersigned by an additional member of staff signing to confirm the record is correct. The written entry must record not just the medication but the quantity received the dose and time of administration. The MAR sheets must record the initials of the person dispensing and administering medication. Medication procedures must also evidence that the system is checked on receipt and signed, to confirm it is received in accordance with prescribing direction. All medication must be retained in the dispensing package with its dispensing label. Medication records should be regularly checked to ensure dispensing directions are adhered to. On examination of the storage area the acting manager was advised to access a more secure locking device as medication is stored in a unit locked by use of a ‘star lock’. This is not a secure device and can be easily opened. The home must evidence that ongoing monitoring and review of mental health needs is undertaken with support from health professionals. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. Procedures must be reviewed to ensure people’s views are listened to and that procedures protect them from harm and neglect. EVIDENCE: The home’s complaints procedure sets out how people can raise concerns about the service they receive. The resident completing the comment card indicated they knew who to speak to if they were not happy about the service they received. The homes complaints register recorded the last complaint as received in October 2003. Evidence should be maintained that where people need the support of an advocate or family member to assist them with any concerns about the care they receive, that arrangements are in place to enable this to happen. No complaints were received by the Commission in the last year. Although the home indicated it had adopted the Manchester Multi Agency adult protection procedures, no copy of the guidelines was available at the time of the inspection. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 18 The home’s own policy and procedure required a number of changes, which were highlighted to the manager at the time of the inspection. The manager was advised to review the procedures in line with Manchester safeguarding guidelines. During discussions with staff, one staff member did demonstrate an awareness of protection principles and what to do in the event of witnessing or receiving information about abusive practice. However, it was difficult to determine the remaining staffs’ understanding of protection procedures due to the fact that English was not their first language. There is a need to ensure all staff are supported by the manager and through training on this topic. On examination of finance procedures, the home must ensure that residents or a person acting on their behalf are consulted about purchases made on behalf of service users. There was no recorded evidence of consultation or consent for purchases of expensive beds and plasma televisions for people, including installation costs. Such equipment should be recorded on the person’s inventory of belongings. Where residents are charged for replacing furniture, this must also be done in consultation with their advocate or representative where appropriate. Such additional charges must be clearly identified in the contracts and Service Users Guide. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. 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. Action must be taken to ensure people live in a homely, comfortable and safe environment. EVIDENCE: Information in the home’s brochure as stated is misleading in relation to an illustration which does not depict the current property. There had been no significant improvement in the decorating of the home and some work carried out at the time of the last visit required redecorating as damp damage was evident to the left wall of the main entrance. Public facilities such as toilets and the smoke room are cramped and required decorating. Bathing facilities are poorly maintained and privacy locks on these facilities did not function. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 20 On examination of the kitchen a number of electric wires and leads required securing to protect people working in this area. This included wiring above the kitchen sink, (risk of lead falling into sink) and leads above a toaster. All electrics must be secured and monitored in terms of excessive numbers of leads in this area. The external vent from the boiler continues to present a risk to people due to it low positioning on the external wall. The home was advised to enclose the vent with a safety cage at the last inspection. This had not been addressed. The boundary fence to the rear concreted area required attention. Both sides and the rear sections were damaged and required repainting or renewal to ensure a secure defined area for people to access. This was identified on the last inspection and had not been addressed. On examination of people’s bedrooms there was little evidence of personalisation of some rooms. Two rooms required decorating and doors to wardrobes and some drawer units required repairing and fitting. It was reported that the shower on the first floor is leaking and could explain the damp damage noted in the main entrance. The fan in the smoker’s room did not work and the room is cramped and needs decorating. The quality of maintenance and decorating programmes in the home continues to be of a basic standard and as a result requires attention more frequently. The room at the front of the building had been divided into a small cramped office leading into a room for staff to use when providing sleep in cover. The wedging of doors open continues to present as a risk to both people living there and staff. This practice must cease. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. 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. Procedures and practices should ensure that staff have the required vocational and client based training they need to meet people’s needs. EVIDENCE: Having a staff team with enough people who have the right qualifications, skills and values to support and promote the quality of life of vulnerable people with high levels of need is essential for all care homes. Staff rotas required reviewing to ensure they clearly demonstrated who was on duty each day providing cover. A template is used of 2 and 3-4 hourly periods of cover. The acting manager was advised to develop a weekly rota of staff hours, to include the name of the staff member and date. The records seen were unclear and did not give accurate details of person on duty. A member of staff present in the home was not listed as on duty for the date examined. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 22 Staff continue to have overall responsibility for delivery of care, domestic arrangements and catering duties. At the time of the visit five people were accommodated. Their health care needs and support on one to one basis was high to ensure they engage in and were supported on meaningful and chosen activities. There was little evidence of positive engagement with people on these visits. Staff should be supported by other health professionals in the delivery of care and development of their skills. On checking staff files, concerns were raised in relation to the homes failure to carry out Criminal Record Bureau checks on two staff. The acting manager was advised to address this as a matter of priority. All required checks must be completed on staff before they start work. Whilst staff may have undertaken the home’s induction and core training programme the home has no system to evidence that staff are competent in the core skills required to support people. It is recommended that the home introduces a system of evidencing staff competence in the implementation of the core skills developed through the home’s training programme. Since the last inspection two staff have signed up for NVQ level II award. With the exception of seven staff members the remaining personnel at the home are family members. There was no immediate recorded evidence of one to one supervision being provided to staff and no records of staff meetings. These are areas requiring attention to ensure effective development and communication systems are in place to support staff. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. 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. Management and administration procedures required developing to demonstrate that the home is run in the best interest of people. EVIDENCE: The registered manager was not available at the time of the inspection. The visits were conducted with the assistance of a designated family member assigned as acting manager in his absence. The overall findings for the visit, failed to evidence any positive action taken by the service to improve the findings at the last visit. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 24 There was little evidence that people living there had been consulted about daily lifestyle arrangements, involved or consulted on meal arrangements or range of social events to meet their preferences. There was little evidence that staff had been provided with training and development programmes to support their skills and knowledge of mental health care needs. There was no evidence of quality assurance systems to evidence that people had been regularly consulted on the service they received. Medication procedures required monitoring and reviewing to protect people. Adult protection procedures required reviewing as directions could be misleading and could corrupt safeguarding procedures. Some sections were contradictory. The home should retain evidence that professionals such as the Community Psychiatric Nurse, dietician and Occupational Therapist had been involved or consulted in the delivery of care. The homes Insurance liability was not current and the home must confirm this is now in place. The document on display had expired on the 12 April 2008. Staff rotas need to be more informative and an accurate record of cover provided, to record staff names and dates they work with listing of hours covered. Finance procedures required reviewing to ensure finances are being managed in the best interest of people being cared for. Management and administration procedures need to effectively evidence that the home is managed in the best interests of people, that the needs of people are being met according to their assessed needs at the time of admission and in accordance with the registration category. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 3 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 2 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 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 2 X X 2 X 3 Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 26 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 4 Requirement Admission procedures must ensure the needs of people referred to the home meet the registered service category. Staff must receive training in meeting all the assessed needs of people living at the home. Care plans must evidence how people are supported on aspects of mental health care and how staff support people. Medication procedures required addressing in relation to: Administration Records should start with a copy of the names of people responsible for its administration and sample signatures of staff. Hand written entries must be signed by the person making the record and should be countersigned by an additional member of staff A record must be kept of the Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 27 Timescale for action 10/07/08 2 YA6 18 10/07/08 3 YA6 18 10/07/08 4 YA20 12 10/07/08 quantity of medication received, the dose and time of administration. The MAR sheets must record the initials of the person dispensing and administering medication. Medication must be retained in the dispensing package with its dispensing label. Medication records should be regularly checked to ensure dispensing directions are adhered to. Medication must be held in a secure area. 5 YA23 18 All staff must be provided with training in safeguarding procedures. Appropriate action must be taken to ensure equipment and in particular electrical wiring and leads in the kitchen are safe to protect people. 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. All staff must have a Criminal Record Bureau check Staff must receive training appropriate to the services registration category, to ensure they can meet the needs of service users. Financial procedures must evidence the home is acting in the best interest of service users. Any additional charges DS0000055957.V361167.R01.S.doc 10/07/08 6 YA24 23 10/07/08 7 YA24 23 10/07/08 8 9 YA34 YA35 18 18 10/07/08 10/07/08 10 YA37 15 10/07/08 Shassab Version 5.2 Page 28 11 YA42 24 must involve consultation with their advocate or representative where appropriate. Such additional charges must be clearly identified in the contracts and Service Users Guide. Management and administration procedures must evidence that the home is managed in the best interests of people 10/07/08 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 YA5 Good Practice Recommendations Evidence should be retained that people have been provided with a contract which assure people or their representative that their assessed care needs will be met. Daily records should be developed to evidence consultation with people regarding daily routines and day to day management of the home. The manager is advised to liaise with professionals such as occupational therapists on more age appropriate activities for people living in the home. All daily recordings are maintained in one ring binder. The manager was advised to set up individual files to ensure issues regarding confidentiality of information and data protection are adhered to. The home is advise to review meal time arrangements for people, so that meal times are held as a social event All food provisions placed in the fridge for storage should be labelled and dated. The descriptive picture of the home, as illustrated on the homes brochure, should be amended, as it is not an accurate reflection of the building. 2 3 YA6 YA6 4 YA6 5 6 7 YA17 YA19 YA24 Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 29 8 9 YA31 YA39 Staff rotas should be reviewing to ensure they clearly demonstrated who was on duty each day providing cover. 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. Shassab DS0000055957.V361167.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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.V361167.R01.S.doc Version 5.2 Page 31 - 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!