Inspection on 25/06/07 for Spinney Hill Road

This inspection was carried out on 25th June 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Spinney Hill Road 17/07/06

Spinney Hill Road 20/02/06

Spinney Hill Road 16/05/05

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Spinney Hill Road 56 Spinney Hill Road Northampton Northants NN3 6DN Lead Inspector Keith Charlton Unannounced Inspection 25th June 2007 10:10 Spinney Hill Road DS0000063583.V341165.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 Spinney Hill Road DS0000063583.V341165.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. Spinney Hill Road DS0000063583.V341165.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spinney Hill Road Address 56 Spinney Hill Road Northampton Northants NN3 6DN 01604 642515 01604 642515 manager.spinneyhill@tracscare.co.uk suehullin@tracscare.co.uk Tracscare Group Ltd 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) Roy Chapanduka Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Spinney Hill Road DS0000063583.V341165.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Spinney Hill Road care home is registered to provide personal care to male and female service users who fall within the following categories: Learning Disability (LD) 3. Mental Disorder, excluding learning disability or dementia (MD) 3. No person falling within the category of MD, Mental Disorder excluding Learning Disability or Dementia, can be admitted into 56 Spinney Hill Road unless that person also falls within the category of LD, Learning Disability i.e. Dual Disability. The maximum number of persons to be accommodated at Spinney Hill Road care home is 3. 17th July 2006 2. 3. Date of last inspection Brief Description of the Service: The home is registered to provide care for up to three people with a Learning Disability who additionally have a Mental Disorder. The house is on a road of similar houses in a residential area of Northampton. Residents are encouraged to be as independent as possible with staff support and supervision. The home is within walking distance of local community amenities, which include shops, pubs and a park. There is a bus service from the estate into town. Accommodation to service users is provided across two floors. All bedrooms are single occupancy, one is on the ground floor with en-suite facilities and two are on the first floor. The ground floor provides a sitting area, kitchen/dinner and conservatory. There is a garden area to the front and rear of the home. The current fees range from £1,800 to £2,137 per week with extra charges for one to one supervision, personal items and persistent wilful damage. The Registered Manager stated that residents and representatives are provided with a service users guide to the services the home offers with the home’s Statement of Purpose and reference to the last Inspection Report. Spinney Hill Road DS0000063583.V341165.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting two residents and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The Registered Manager was not on duty for the first day of the inspection so other support staff assisted instead. Planning for the Inspection included assessing any notifications of significant events sent to the Commission for Social Care Inspection by the home. There have been no complaints received regarding the home since the last inspection. The Inspections took place between 10.10 and 14.40 on day one and completed two days later with the Registered Manager, and included a tour of the building, inspection of records and indirect observation of care practices. The Inspector spoke with two residents, two members of staff, and the Registered Manager. What the service does well: The service focuses on residents’ individual needs, e.g. residents spoken with said they liked living in the home and thought staff were largely friendly, that they liked their activities and their bedrooms. Care Plans are comprehensive and detailed to assist staff to deliver care that fits individual residents care needs. Individual Activities Programmes help residents plan their time, provide stimulation and assist them to work towards their goals. Staff were found by the inspector to be largely positive and friendly in their dealings with residents, and encouraged them to make choices. Bedrooms are personalised and organised to residents’ styles of living with personal possessions in them to make them homely. Facilities are kept in a clean and tidy condition and decor is bright. Spinney Hill Road DS0000063583.V341165.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Spinney Hill Road DS0000063583.V341165.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 Spinney Hill Road DS0000063583.V341165.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 good. This judgement has been made using available evidence including a visit to this service. An assessment system to meet residents needs is in place, which ensures that people receive the correct care. EVIDENCE: A resident said that he visited the home for a trial before he made up his mind about coming to live there to meet the other residents, staff and view facilities before making a decision as to whether to move there. There was also evidence that the appropriate information such as the Service Users Guide had been supplied to residents. Evidence seen by the inspector showed that there are detailed social work assessments. All of the residents selected for case-tracking purposes had appropriate contracts in place, though not all had been signed by the resident or their representative. This was discussed with Registered Manager who has agreed to follow this up. Spinney Hill Road DS0000063583.V341165.R01.S.doc Version 5.2 Page 9 The home’s Annual Quality Assurance Assessment stated that residents and their representatives are given adequate information about the home as they are provided with copies of the Service use Guide and Statement of Purpose, that residents needs are fully assessed by the management and clinical personnel to ensure their needs and expectations can be fully met by the service, and they are assessed for compatibility with other residents to avoid any negative impact on their lives. Opportunities are given for sleep overs and an introduction to the local community and amenities. Residents needs are to be assessed in future using the detailed Tracscare assessment tools to ascertain if their needs can be met. The service has purchased Communicating in Print Software and the Registered Manager said he would be converting all word documents for residents to the format they understand - Writing with Symbols. Spinney Hill Road DS0000063583.V341165.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): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual needs and choices of people living in the home are generally well met though daily living choices need to be reviewed to ensure residents can choose when they wish to rise and retire. EVIDENCE: Residents spoken with thought they were generally well looked after by staff with one exception, which is being followed up by the Registered Manager. There was a query as to how residents were encouraged to go to bed/ get up etc. The Registered Manager said that residents wishes would be ascertained and followed. Evidence was seen of a range of risk assessments, which addressed activities chosen by residents that may present risk. These included safety in the Spinney Hill Road DS0000063583.V341165.R01.S.doc Version 5.2 Page 11 community. Risk assessments identified aspects of each resident’s care needs that resulted in increased vulnerability. This is good practice. There was evidence of professional visits and reviews. All residents have detailed care plans and they now have advocates to represent their interests. There is now information as to wishes about terminal care and death, and Health Action Plans are to be completed for individual residents. Staff spoken with were knowledgeable about the care and support each service user required and they said they were expected to read Care Plans. Staff were observed offering choices to residents, e.g. what activities they wanted to do that day, what food they wanted etc. Residents are involved in planning the weekly menu and food shopping. Staff said that there are one to one meetings with residents to ascertain their wished regarding holidays, activities, décor etc and there was evidence of this. The Registered Manager said he planned to introduce residents meetings at two monthly intervals. There was evidence that residents complete questionnaires about the care they receive and their representatives and family also have this opportunity. This is being done from central office and the results for the most recent one are due soon. One questionnaire inspected referred to a resident stating he was not listened to. The Registered Manager said this would be followed up to ascertain why he felt like this with action taken as needed. Spinney Hill Road DS0000063583.V341165.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is good evidence that residents have the opportunity to have fulfilling lifestyles. EVIDENCE: Spinney Hill Road DS0000063583.V341165.R01.S.doc Version 5.2 Page 13 Residents spoken to said they had their daily programmes, confirmed in their Care Plans, and they generally liked to do their activities. Residents said they go to the Gateway club, to pubs, which they said they liked doing. There was evidence of activities – music, cooking, going out to activities – colleges, discos, local pubs, horse riding etc. One resident does not go out for day care. It was discussed as to how this resident could be offered additional opportunities of activities she liked e.g. horse riding. Records showed that residents have been asked where they want to go on holiday. Residents Meeting notes showed that they have been consulted and trips are planned in the future. Staff said that residents use a range of community facilities including local shops, pubs, the park, the post office, to get their money as well as attending specific groups for people with learning disabilities. The inspector case tracked two care records, which again clearly demonstrated that residents changing needs are being monitored and supported whilst living at the home. Records, observations and discussions with residents demonstrate that they can make most decisions about their lives and independent life styles are encouraged, e.g. a resident has gone from staff assistance when going out to being able to go out, that residents are encouraged to do household chores, do as much of their personal care as possible, they can get their own breakfasts, and they are asked where they want to go on holiday etc. This philosophy is reflected in the service users guide. Residents are asked their views on important issues in their meetings and these are recorded regarding food, holidays, outings etc. The Annual Quality Assurance Assessment stated that the service has requested a bigger vehicle from the company as a result of residents saying it is not comfortable enough for them when full. Also that residents will be completing their current studies at Northampton College this year. They will then be enrolled for more courses that help them develop their independence skills. Residents said they could have their visitors to the home and that there were no restrictions on visiting times. Staff members said that it was important for residents to maintain contact with their friends and family. There were comments received from residents regarding the food being good. Lunch that day consisted of sandwiches, with a choice of fillings and a salad. Food records did not show that residents were given a choice of food for each meal or record what vegetables are offered to residents. The Registered Manager said full recording of food would occur in the future though residents tended to choose to have the same food. Spinney Hill Road DS0000063583.V341165.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): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents physical and emotional health needs are being well met. EVIDENCE: There is comprehensive information kept in Care Plans, which details all medical appointments and check ups on an individual basis - from nurses, GPs, dentist, speech and language therapist etc. Care Plans indicate all aspects of residents health care needs are covered – e.g. management of personal care, monitoring weight, communication, social skills, work and play etc. Accident Records were checked and it was found that in general staff had reacted appropriately to all situations presented, though more detail was needed to one accident where it did not state what treatment the resident received. The Registered Manager said that if there were head injuries they would be referred to medical services for assessment. Spinney Hill Road DS0000063583.V341165.R01.S.doc Version 5.2 Page 15 Staff stated that the pharmacist has trained all staff that deal with medication, which was evidenced on file, and the Registered Manager also said that he also assesses staff competence before allowing staff to issue medication. The Annual Quality Assurance Assessment stated that residents are risk assessed to determine whether they can self- administer medication. Where this is not possible, they sign a consent form for staff to do this on their behalf. The Registered Manager said medication is audited regularly to ensure correct administration and accurate record keeping. Medication records were checked by the inspector and found to be up to date, with only one query where a tablet had been recorded as being given but was still in the blister pack. The Registered Manager said this had been followed up. Medication is kept securely locked away. Incoming and returned medication recording was checked and found to be in order. Spinney Hill Road DS0000063583.V341165.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): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents welfare is protected by the procedures of the service and staff training is provided to ensure the proper process of protecting residents from abuse is followed. EVIDENCE: Residents said that if they were worried about anything they would speak to staff and they generally thought it would be followed up. The Commission for Social Care Inspection has received a notification regarding a recent incident, which is being followed up at present. There were no records in the complaint book of residents complaining though one resident has complained on a number of occasions – this needs to be recorded with details of how the issues were followed up. The Complaints Procedure seen by the inspector reflected the National Minimum Standard, though needs to be altered to direct the complainant to the local Social Service Department, who are now responsible for complaints investigations. Staff members on duty were asked about their understanding of whistle blowing procedures, and both demonstrated a generally good understanding of Spinney Hill Road DS0000063583.V341165.R01.S.doc Version 5.2 Page 17 the protection of residents from abuse. There was evidence on file that staff had received Vulnerable Adults protection training. The Annual Quality Assurance Assessment stated that residents are aware of the complaints procedure, which is regularly explained to them, that staff attend the Protection of Vulnerable Adults Training within the first few weeks of employment, and that all staff have appropriate Criminal Records Bureau Clearances and POVA first checks, with local procedures in place to report any suspicions of abuse to relevant people. Residents now have advocates who represent their interests. Spinney Hill Road DS0000063583.V341165.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comfortable environment is provided to residents with a good standard of hygiene. EVIDENCE: Residents said that they liked their bedrooms and they could have their things in them. Some residents showed the inspector their bedrooms. They said they were encouraged by staff to tidy their bedrooms and make their beds. Observations of the bedrooms demonstrated that décor in their bedrooms was bright - one bedroom is due for redecoration in the near future. Communal areas looked comfortable and clean. Standards of cleanliness and odour control in all areas of the home were good. Spinney Hill Road DS0000063583.V341165.R01.S.doc Version 5.2 Page 19 There were a number of doors that squeaked and shut loudly, which could irritate residents. The Registered Manager said they would be attended to. There were no towels in a bathroom on both days of the inspection. The Registered Manager said he would remind staff to do this task. The grass to the garden was long and needed cutting. The Registered Manager said this would be carried out and he showed the inspector the garden plan to upgrade this space. It was recommended that smoking stickers are not displayed if they are not strictly required by law (please check with the Environmental Health Officer to see if care homes are exempt) as they take away from the homely ambiance of facilities. The Annual Quality Assurance Assessment stated: Carpets in the front entrance and conservatory have been replaced with easy to clean laminate flooring, carpets on the staircase and landing have been replaced, wall paper on the stair case walls and landing has been removed and redecorated with a bright neutral colour scheme. The lounge has been refurnished and repainted. A new dining table and furniture for the conservatory have been purchased. All residents rooms have new beds and all will have new wardrobes. One resident, with parental involvement, chose different furniture and this was purchased by the company. New curtains that black out light in summer were fitted in bedrooms 2 and 3. Also during the first two weeks of August 2007 the kitchen is to be refurbished. The en-suite in bedroom 1 is to be refurbished at the same time. One bedroom will have new purpose built tough furniture because of this resident’s needs. The resident has chosen the colour of the paint he wants for his bedroom. Spinney Hill Road DS0000063583.V341165.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): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a dedicated staff group, with sufficient staff numbers on duty to meet residents needs. EVIDENCE: Spinney Hill Road DS0000063583.V341165.R01.S.doc Version 5.2 Page 21 Residents spoken to were satisfied in general with staff and saw them as largely helpful and friendly, although there was a negative comment regarding a staff member, which the Registered Manager is to follow up. The inspector observed that staff were generally helpful to residents though there were a small number of occasions where residents were not given attention, which could have led to frustration and challenging behaviour. The Registered Manager said this would be monitored to ensure that staff are always attentive to residents. There was a comment on a Quality Assurance survey from a Social Worker that residents may find some staff accents hard to understand. The Registered Manager said he would discuss how this issue could be tackled with the line manager. Staffing levels during the course of the inspection met the relevant minimum standards. There are two to three care staff on duty during daytime/evening periods, and this was found to be the case by the inspector, with an awake staff member at night and a staff member on duty on call if needed. This relatively high staffing ratio is needed because of the challenging behaviour of residents. It was noted by the inspector that staff were working up to fourteen hour shifts, which considering the challenges they continually face whilst working, could well lead to fatigue and impaired work performance. The Registered Manager said this would be reviewed. There was a discussion regarding when only a sole member of male staff is on duty at night with a female resident in the home. The Registered Manager said that there were no risk factors regarding this. This needs to be formally risk assessed. Staff records were inspected and found to have all the necessary statutory checks, so as to protect residents from unsuitable staff. A Risk Assessment is needed if any staff have previous cautions/offences. The Registered Manager said this would be carried out. Staff members were spoken to and had a good knowledge of residents care needs and were committed to providing a good service. There was evidence on files that they are to be supplied with regular supervision. There was evidence of a formal induction programme and new staff now receive staff booklets based on the Learning Disability Award Framework. Staff said they weekend encouraged to attend National Vocational Qualification level 2 and 3 training. The Annual Quality Assurance Assessment stated that all staff have now been registered with Skills for Care and have now started doing a new intensive induction programme, that staff will be updated on any new sector training requirements e.g. Mental Capacity Act and Skills for Care programmes. Spinney Hill Road DS0000063583.V341165.R01.S.doc Version 5.2 Page 22 The Registered Manager has a training programme, which includes staff achieving National Vocational Qualification qualifications. The Registered Manager said staff will all have training on a wide range of topics – e.g. Fire, Food Hygiene, First Aid, training in residents conditions, e.g. all mental health conditions, Autism, Protection of Vulnerable Adults, Food Hygiene etc. However not all staff had received such training yet, as indicated on the staff training matrix. All staff also need training in coping with challenging behaviour, which was acknowledged by the Registered Manager. The Registered Manager agreed that such training would be completed in the next six months. Spinney Hill Road DS0000063583.V341165.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): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the generally proactive management of the home though more attention needs to be paid to fully ensuring fire safety. EVIDENCE: The manager holds a National Vocational Qualification level 4 (Registered Managers Award). Spinney Hill Road DS0000063583.V341165.R01.S.doc Version 5.2 Page 24 Staff said they thought that the Registered Manager runs the home in a positive way, which promotes residents interests and values their input. The Registered Manager said that there have not been regular staff meetings recently but he plans to hold them every two months, as per the National Minimum Standard. Residents and other interested parties – relatives, GPs, Nurses, Social Workers etc are to be asked as to their views on the way the home is run through a detailed Quality Assurance survey. The Registered Provider then needs to analyse the results of surveys, to produce an Action Plan to cover any issues raised and include this information in the Statement of Purpose. The Registered Manager stated that there are now Policies and Procedures that cover all issues except continence care. The inspector asked that this is followed up, which the Registered Manager said would be done. Fire records showed that a fire drill had not been held for over seven months and there needs to be more detailed records kept to record who has taken part in the drill and what happened, regular testing of fire bells was slightly behind the weekly schedule, though regular emergency lighting testing was in place. The fire risk assessment is in place though this stated that fire doors should not be wedged open – the kitchen and lounge doors were found to be wedged and did not shut on their rebates, thereby compromising fire safety. The Registered Manager quickly followed up these issues by ensuring work was carried out to the rebates on doors and fire doors were observed to be closed on the second day of the inspection. Staff members were asked as to the fire procedure and were aware of this. Some residents monies were checked and found to be in order. Records had receipts and running balances, though did not always have two signatures for each transaction – the Registered Manager said this would be followed up. Monies are checked on a daily basis to ensure they are correct. This is good practice. In terms of health and safety there are Risk Assessments for safe working practices in place, Control of Substances Hazardous to Health assessments, protected radiators, and window restrictors in place. Health and Safety Policies and Procedures are in place and staff said they are encouraged to read them. The hot water temperature was measured and found to be in accord with the National Minimum Standard. As the National Minimum Standard is 43c, water can be hotter than this if residents wish to have a warmer bath, subject to a Risk Assessment. There were hot water monitoring charts in place to ensure residents are protected from scalding temperatures. Spinney Hill Road DS0000063583.V341165.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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 X 35 2 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 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 1 X Spinney Hill Road DS0000063583.V341165.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 YA42 Regulation 13 Requirement Fire systems need to be strengthened to ensure that there is full fire safety in the home. Timescale for action 02/07/07 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. Refer to Standard YA32 YA35 Good Practice Recommendations A review of staff shifts is needed to ensure that working excessive shifts does not unduly fatigue staff. All staff need to be trained in essential identified issues. Spinney Hill Road DS0000063583.V341165.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Spinney Hill Road DS0000063583.V341165.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. 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