Inspection on 10/07/07 for Shieling The - Coach House The

This inspection was carried out on 10th July 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shieling The - Coach House The 18/07/06

Shieling The - Coach House The 15/11/05

Shieling The - Coach House The 18/11/04

Shieling The - Coach House The 15/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Shieling The/ Coach House The 58 Harlow Moor Drive Harrogate North Yorkshire HG2 0LE Lead Inspector David White Key Unannounced Inspection 10th July 2007 09:30 DS0000007909.V334216.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 DS0000007909.V334216.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. DS0000007909.V334216.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shieling The/ Coach House The Address 58 Harlow Moor Drive Harrogate North Yorkshire HG2 0LE 01423 508948 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) www.craegmoor.co.uk Parkcare Homes Limited Miss Joanne Metcalfe Care Home 13 Category(ies) of Learning disability (13) registration, with number of places DS0000007909.V334216.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th July 2006 Brief Description of the Service: The Shieling provides residential personal and social care for 11 adults aged between 18 and 65 years old who have learning disabilities and may present other complex needs. The home is a large semi detached property situated close to Harrogate town centre and with good access to its services and amenities. The registered provider is Parkcare Homes Ltd a subsidiary of Craegmoor Healthcare UK Ltd. The registered manager is Miss Joanne Metcalfe. The current fees for the home at the time of the site visit on 10th July 2007 range from £450 to £1550 per week and do not include costs for chiropody, hairdressing and toiletries. Current information about services provided at The Shieling is available in the form of a statement of purpose and service user guide that explains the care and services on offer at the home. DS0000007909.V334216.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • Reviewing information that has been received about the home since the last inspection. Information provided by the manager on a pre-inspection questionnaire. Comment cards returned by two relatives. This report follows an unannounced site visit undertaken on the 10th July 2007. This visit was carried out by one Regulation Inspector and took 6.5 hours with 4 hours preparation time. Time was spent talking to two people who live at the home; a member of care staff, the deputy manager and the manager. Records relating to people at the home, staff and the management activities of the home were inspected. During the visit care practices were observed, where appropriate, and time was also spent watching the general activity in the home. This helped in gaining an insight into what life is like for people living in the home. The manager was available for some of the inspection but due to other commitments was not available for the latter part of the site visit so the findings were discussed with the deputy manager. What the service does well: People at the home are encouraged to live their lives as they prefer so that they have control over their own lives. People say that they feel “well cared for” by the staff team so that their needs are met. Good care planning systems mean that staff receive clear guidance on how to deal with difficult and challenging behaviours from individuals so that the distress to the individual and others is minimised. People at the home have good access to health care services so that any health needs are addressed properly. The home has a stable and settled staff team so that people at the home receive a good consistent standard of care from people who know them well. There is a friendly atmosphere at the home and this makes people living at the home feel comfortable and safe. DS0000007909.V334216.R01.S.doc Version 5.2 Page 6 The manager and staff team work hard to improve the quality of lives of people living at the home. What has improved since the last inspection? What they could do better: DS0000007909.V334216.R01.S.doc Version 5.2 Page 7 Improvements could be made to the way complaints are recorded in order to make sure that people’s concerns are fully addressed and properly acted on. Better arrangements could be put in place to make sure that the numbers and skill mix of staff on duty at any particular time is sufficient to meeting the needs of people at the home. 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. DS0000007909.V334216.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 DS0000007909.V334216.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): 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Proper pre-admission procedures are in place so that people who are thinking about moving into the home can feel confident that their needs will be met. EVIDENCE: The home has a pre-admission policy that outlines the procedures that need to be followed when people are considering moving into the home. One person has moved into the home since the previous inspection visit. This person was initially admitted into the home for an emergency placement and the care records show that information had been sought from the placing authority about the person’s suitability before their admission. The home has carried out their own assessment of the person’s needs and a care plan is developed from this so that staff have guidance and are clear about how their identified needs are to be met. In the case of the most recently admitted person to the home it was not practicably possible for them to visit the home before they moved in. However in all other cases people who are thinking about moving into the home would be offered the chance to visit the home beforehand. DS0000007909.V334216.R01.S.doc Version 5.2 Page 10 Since the previous inspection visit there have been a number of incidences involving one particular person who was living at the home. Following ongoing review of this person’s care a joint decision was made that the home was no longer suitable for this individual and an alternative placement has been found in order to meet the person’s needs and those of the other people living at the home. DS0000007909.V334216.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People are encouraged to make their own choices about how they live their lives and this is supported by a new care planning system that takes into account any risks that need to be considered. EVIDENCE: People living at the home said that they feel “safe and well cared for”. One person described their daily routines and said that they made their own decisions about what to do during each day. A comment card received from a relative stated that the home “always meets the needs of my relative” and another said that their relative could “live the life that they chose”. Person centred plans are being introduced for every person at the home. These focus on how people prefer to be supported in meeting their aims and objectives. The views of their relatives and professionals who are involved in DS0000007909.V334216.R01.S.doc Version 5.2 Page 12 the person’s care are considered as part of this process. The new documentation includes information about the person’s life history, their personal choices about their preferred daily routines, their hobbies and interests, social networks and friendships and their likes and dislikes. This has improved the quality of the care planning documentation and staff said that they found the information to be useful and “easy to follow”. Some of the information in the new documentation is in picture format so will help people with communication difficulties to have involvement in the planning of their care. The home has a key worker system in place and each month staff meet up with each person where possible to discuss their care. Information from this meeting is recorded in a “client supervision record”. Care plan reviews take place on a periodic basis and involve the person at the home, relatives and other people who are involved in their care. People said that they are encouraged to be independent and a range of risk assessments are carried out to support people with this and to promote their safety. The assessments include information about how decisions have been made where people could be restricted in what they are able to do and these are agreed with the person where possible. Staff said they are clear about what actions to take when individuals challenging behaviour that challenges the service and have received training to support them with this. The care plans and risk assessment documentation detail clearly what actions are to be taken in order to minimise any risks from an individual’s behaviour. Daily records reflect the care that is being given and these are up to date. DS0000007909.V334216.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People living at the home enjoy a range of activities to suit their personal needs and have involvement with the local community. EVIDENCE: Each person has an individual activity programme that is aimed at developing his or her personal skills and interests. Although most of the people at the home attend the Vocational Skills Centre (VSC) that is run by Creagmoor some individuals choose to spend most of their time around the home. The home provides transport for people who attend the VSC. One person said that they did not want to attend the VSC on a regular basis but was able to go when choosing to do so. Some people enjoyed going to the local social clubs and other community facilities such as the pubs, cinema and bowling centre. Day outings are planned and arranged with people DS0000007909.V334216.R01.S.doc Version 5.2 Page 14 in house meetings and a holiday has been booked for Skegness for later in the year. Some of the people at the home have their own television and music systems. The home also has a television and music facilities in the communal lounge. People can see their family and friends whenever they wish and the care records show that relatives are kept informed about their relative’s wellbeing and are involved in the planning of their care. One person said that they regularly receive visits from their family. People have access to a telephone if they wish to contact family and friends at any time. Meals are planned with people in advance. People living in the home said that they enjoy the meals on offer and that there is always choice available. Fresh fruit is offered between meals however it was observed from the menu options and checks of food supplies that there are limited healthy eating options such as fresh vegetables. Whilst it is acknowledged that people at the home make their own decisions about the foods they eat, it is recommended that the menu planning be reviewed to encourage more healthy eating options. DS0000007909.V334216.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The personal and healthcare needs of people at the home are being met. EVIDENCE: The care records of each person living at the home provide detailed information about how support is to be given to them. People at the home said they receive personal support to suit their needs and this was observed at the time of the site visit. Each person at the home has a General Practitioner (GP) and access to other health care services. Referrals to specialist services are made as appropriate and the records show that staff support people in attending their appointments. There have been improvements in the recording of health care information in the care records so that it is now clear the reasons why people have attended appointments and the outcomes and actions to be taken from this in order to make sure that people’s health needs are met properly. One person has a medical condition that can sometimes lead to their admission into DS0000007909.V334216.R01.S.doc Version 5.2 Page 16 hospital. In their care records there is a personal checklist that provides good information about the individual such as their communication ability and this information is shared with hospital staff in the event of the person being admitted into hospital so that they are aware of the person’s needs. A number of people have involvement from the local Community Learning Disability Team and mental health services and this helps in ensuring that people receive the most appropriate kind of support in meeting their needs. A relative made comments that the home is good at communicating important matters to them about their relative’s health. There has been an improvement in the medication arrangements for the home. The home is using the Boots monitored dosage system and staff made comments that they are finding the new system much easier to use so that there is less risk to people at the home from medication errors. The medication administration records show that all medication is given as prescribed and there have been improvements in the recording and reasons for why prescribed medications have not been given so that there is an explanation as to why medication has been omitted. Proper arrangements are in place for the receipt and disposal of medicines and a random check of some medication supplies tallied with the records. At the present time none of the people living at the home are able to safely administer their own medication and risk assessments have been carried out to support how these decisions have been made. Staff who administer medication have all received the necessary training and have updates as needed. DS0000007909.V334216.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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People living at the home are safeguarded from possible abuse. Although a complaints procedure is in place, this is not being fully followed and could lead to people’s concerns not being fully addressed and acted on. EVIDENCE: The home has a complaints procedure that is on display in the home and which details how people can make a complaint and what actions would be taken from this. Since the previous inspection visit the manager has sent letters out to all relatives providing them with details of the home’s complaints procedure. The home has received four complaints since the previous inspection visit. The information about the nature and outcomes from the complaints are only briefly recorded together in a complaints book, as there is no system in place to log individual complaints. This practice needs addressing to safeguard people at the home and to make sure that data protection standards are met. The manager said a recent audit of the home by Craegmoor’s clinical governance team had also identified that complaints need to be logged individually and a copy of the findings from the audit confirmed this. Within the records of complaint there is very little information about the investigations that took place, the timescales for responding to the complaint, outcomes and the actions that were taken by the home. There is also a lack of information about how individuals are updated on the progress and outcomes of any complaint they may make. This needs addressing so that proper procedures DS0000007909.V334216.R01.S.doc Version 5.2 Page 18 are followed in making sure that people’s concerns are fully acted on to safeguard their interests and to monitor the nature and number of complaints being received by the home in order to improve its service. The home has policies and procedures in place for the safeguarding of vulnerable adults from abuse. Since the previous inspection visit a person living at the home had made an allegation of abuse concerning another person at the home. Proper procedures were followed and the matter was referred to the appropriate authority. Following investigation no further action was taken. Staff have all attended some abuse awareness training and receive regular updates and a new member of staff said they had been made aware of issues around abuse as part of their induction to the home. DS0000007909.V334216.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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Improvements have been made to the living environment to promote the comfort and safety of people living at the home although further work needs carrying out to continue the progress that has been made. EVIDENCE: The home has four floors that can only be accessed by stairs so it is not suitable for people with mobility problems. Each person has their own bedroom that is personalised to suit their individual tastes. Only one bedroom has ensuite facilities but toilets and bathrooms are accessible to all the people at the home. The home has a garden and paved patio area to the rear of the building where people can sit and smoke if they choose to do so. There is a dining room where some people like to sit and a separate lounge area with a television. People said that they liked their bedroom and the comfort of the home and a relative made comments that the home is “warm and comfortable”. DS0000007909.V334216.R01.S.doc Version 5.2 Page 20 Since the previous inspection visit a number of improvements have been made to the environment. A lounge door has been fitted with a door closure to offer people more privacy and safety. A bedroom that had suffered water damage has been repaired and repainted and the carpet on the second floor had been replaced to prevent any risks from tripping. Loose tiles in the freezer and dry storeroom have been replaced and the ventilation system in the laundry area has been cleaned to minimise risks of infection to people at the home. A dishwasher has been bought and this will promote good hygiene practices and enable staff to have more time to spend with people living at the home. Extra chairs have been purchased so that more people can sit in the dining room area if they choose to do so although the manager is looking to acquire better quality furniture for this particular part of the home. Some areas of the home have been redecorated and on the day of the site visit the home was clean and had no offensive odours. At the time of the site visit the gas boiler had broken down and the manager addressed the problem immediately so that the situation could be rectified. It was noted that the shower rail in the second floor bathroom was rusting and this needs addressing so that people are not at risk to their health and safety. The home looks brighter following some of the re-decoration work but other parts of the home are in need of refurbishment and in particular to the décor on the landings and ceilings on all floors. The home has a rolling maintenance programme. There are separate laundry facilities where people’s personal clothing and bedding are attended to and procedures are followed to prevent the risk of infection. DS0000007909.V334216.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, 33, 34 and 35 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People living at the home receive a good and consistent standard of care from a settled staff team who are appropriately trained to meet their needs. Better staffing arrangements would help to make sure that people’s needs are met at all times. EVIDENCE: On the day of the site visit the atmosphere in the home was friendly. The home has a settled and stable staff team who have a good understanding of the needs of the people living at the home. Staff made comments that they enjoy working at the home and people living at the home said they feel they are well cared for. Since the previous inspection visit staffing levels between 9am and 4pm have been increased so that there are always at least two staff on duty. At the time of the site visit there were three people in the home and two staff on duty. However one member of staff was the manager and the other was a newly appointed person who had started working at the home only four weeks earlier. This person had not completed induction and was limited in DS0000007909.V334216.R01.S.doc Version 5.2 Page 22 what they were able to do due to their level of experience and training. This therefore potentially placed restrictions on people at the home such as a situation where a person who may wish to go out but whom needed staff support to be able to do so. The duty rotas show that there have been other occasions recently when the new member of staff was the only person on duty in a morning with another person and this needs addressing so that the staffing skill mix ensures that all the needs of the people at the home are being met. The manager as well as attending to the needs of the people at the home was also dealing with management duties and it was observed that at times the staff looked under pressure. There are current shortfalls in the staffing levels and a member of staff made comments that a number of staff are working extra hours to cover shifts. In the past Creagmoor Healthcare have experienced difficulties in recruiting new staff, however measures have been taken to address this issue by re-advertising for care staff with improved rates of pay. The manager said that this had led to a better response to job vacancies and from this new staff have been appointed pending satisfactory police and other pre-employment checks. The staff file of the most recently employed member of staff shows that proper recruitment procedures are followed with all the necessary checks in place prior to new staff starting work at the home so safeguarding people at the home from possible harm. Staff at the home receive a range of training, including training specific to the needs of the people at the home. Some autism training is planned for all staff, who have attended some informal sessions on mental health issues although it is recommended that more formal training be provided in order to promote their knowledge and skills in meeting the needs of people with mental health problems. The home has an ongoing programme for staff to undertake the National Vocational Qualification (NVQ) to develop staff’s knowledge and skills. DS0000007909.V334216.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home is managed in a way that encourages people living there to be involved in decision making about how the home is run and protects their health and safety. EVIDENCE: The registered manager is experienced in running the home and is about to complete the Registered Manager’s Award to enhance her management skills and knowledge. People living in the home and staff said that she is “supportive and approachable”. DS0000007909.V334216.R01.S.doc Version 5.2 Page 24 The manager has worked hard to bring about improvements in the home. As well as managing The Shieling and working extra hours to cover vacant shifts, she has also been overlooking the management of another nearby Craegmoor home. This situation should be helped by the recent recruitment of additional members of staff to The Shieling and appointment of a manager to the other Craegmoor home. There are systems in place for seeking the views of people about the running of the home. Annual surveys are sent to people at the home and their relatives asking for their comments on the care and services on offer. These are returned to the organisation’s head office and the findings are summarised and an action plan requested from the home as to how they are to address any areas for improvement. Relatives and others who are involved in a person’s care are invited to attended care plan review meetings. House meetings are held between people at the home and staff to discuss issues and plan activities. The company has a clinical governance team who are responsible for improving quality in the home. They carry out regular audits of different aspects of the home in order to identify areas that could be made better. Records from their recent audit of the home provide very positive comments about the performance of the home. Regular staff meetings take place to enable staff to provide their views and comments about the running of the home. Improvements have been made to some health and safety matters. A plumber addressed previous problems with the hot water systems satisfactorily and periodic checks are now being made by a water testing company to reduce any risks to people at the home from Legionella. Water temperatures are tested regularly and are recorded to make sure that water temperatures are within safe limits and do not put people at risk of harm. Fire safety is well maintained through fire safety checks and regular staff training and the registered manager has carried out a detailed fire risk assessment of the premises. A recent environmental health authority visit identified no areas of concerns and proper procedures are followed to maintain food safety practices. A random check of health and safety documentation was found to be satisfactory with all the necessary checks up to date. Personal information about people living at the home is now securely stored in a locked cabinet. DS0000007909.V334216.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 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 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X DS0000007909.V334216.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 YA22 Regulation 22 Requirement Arrangements must be put in place so that all complaints are logged, timescales are detailed and actions and outcomes are recorded and made known to the complainant. This will help in ensuring that people’s concerns are properly addressed to safeguard their interests. Staffing levels and skill mix must be sufficient and appropriate at all times in order to make sure that the needs of each person living at the home are being met. Timescale for action 10/08/07 2. YA32 18 (1) 10/07/07 DS0000007909.V334216.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA17 YA24 Good Practice Recommendations More healthy eating options should be introduced into the menu to promote the health of people living at the home. In order to improve the standard of the living environment for people living at the home arrangements should be made to: • • 3. YA35 Replace the shower rail in the second floor bathroom. Update the décor on all the landings in the home and to the ceiling areas above these landings. Staff should receive more formal mental health training in order to develop their knowledge and skills in meeting the needs of those people with mental health problems as well as a learning disability. The registered manager should complete the Registered Manager’s Award to enhance her management skills and knowledge. 4 YA37 DS0000007909.V334216.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 DS0000007909.V334216.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!