Inspection on 23/08/07 for St Alban`s Cottage

This inspection was carried out on 23rd August 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Alban`s Cottage 06/09/06

St Alban`s Cottage 02/02/06

St Alban`s Cottage 10/05/05

St Alban`s Cottage 29/09/04

St Alban`s Cottage 04/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 St Alban`s Cottage 2a St Alban`s Close Harehills Leeds West Yorkshire LS9 6LE Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 23rd August 2007 09:45 St Alban`s Cottage DS0000001496.V347359.R02.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 St Alban`s Cottage DS0000001496.V347359.R02.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. St Alban`s Cottage DS0000001496.V347359.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Alban`s Cottage Address 2a St Alban`s Close Harehills Leeds West Yorkshire LS9 6LE 0113 240 1837 0113 2401837 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) None United Response vacant post Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places St Alban`s Cottage DS0000001496.V347359.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2006 Brief Description of the Service: St. Albans Cottage is a four-bedroom bungalow, purpose built to accommodate people with multiple disabilities, who do not require nursing care. The bungalow is situated at the head of a cul de sac in a quiet residential area just off the York Road in East Leeds, with nothing to distinguish it from the outside as a care home. The area is a short distance from local shopping centres, sports and leisure facilities, with good access via public transport from Leeds. The home accommodates four young adults with learning disabilities and some physical disabilities, all of whom are wheelchair users. The property is managed by a housing association but the care service is provided by United Response, a national charity specialising in the field of learning disabilities. There is a new Manager in post, who has yet to apply for registration, and there is close line management supervision from the area office in York. The fees charged by the home ranges between £1345.20 and £2018.80 per week. This information was provided on 23 August 2007, during the inspection. St Alban`s Cottage DS0000001496.V347359.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out a site visit between 9.45am and 5.00pm. During the inspection process all of the key standards were looked at to try and find out what it was like to live at the home. The last key inspection was carried out in September 2006. An annual quality assurance assessment (AQAA) was completed by the home and this information was used as part of the inspection. Surveys were sent to people who live at the home, their relatives and healthcare professionals. Five surveys were returned and responses have been included in the inspection report. Three surveys were received from people who live at the home, all of which were completed with help from staff. Feedback was given to the manager at the end of the visit. During the visit the inspector looked around the home, spoke to people who live at the home, staff and the manager. People who live at the home have complex needs and communication is very limited. Interaction between staff and the people who live at the home was observed. Care plans, risk assessments, healthcare records, meeting minutes, and staff recruitment and training records were looked at. What the service does well: People who live at the home completed surveys with the help of staff. Surveys were positive about the care they receive. They said: • We like living at the home • We feel well cared for • Our privacy is respected • We like the food One relative survey was received. This was very positive and said the home always meets the needs of the person. Under the ‘what do they do well section, it said the home do very well for the people they care for, and under the section how can they improve they wrote ‘ I don’t think it can be improved …as it’s the best it ever could be’. People have an active lifestyle and get lots of opportunities to go out. Recreational activities include manicures, foot massage, BBQ, going out to the park and for walks, meals out, trips to shopping centres and day trips. Everyone works hard to make sure people are offered choice and given opportunities to make decisions. The home is pleasant and people who live there are comfortable in their surroundings. St Alban`s Cottage DS0000001496.V347359.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Care plans and risk assessments had not been regularly reviewed so some information was out of date. General recording systems must improve because some information was difficult to find and other information was missing. Details of how much each placement costs per week had not been given to people who live at the home or their representatives, and was not available in the home, although the manager did obtain the cost of each placement from her line manager on the day of the inspection. People at the home pay towards a vehicle but they do not get many chances to use it and it was unclear how much they pay. There have been three medication errors in a short period of time and there was no record to say how they were going to make sure it wasn’t going to happen again. These errors should have been reported to the Commission but they were not. Staff had not attended some important training that gives them knowledge and skills to keep people safe. Some maintenance work is needed to make sure that people live in a clean and hygienic environment. The home has not had a registered manager for over two years. The manager was in the process of completing her application and anticipated that she would submit it before the end of September 2007. The home will benefit from St Alban`s Cottage DS0000001496.V347359.R02.S.doc Version 5.2 Page 7 having a registered manager to provide the home with continuity and consistency. Requirements and recommendations to address the shortfalls have been made and appear at the end of the report. 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. St Alban`s Cottage DS0000001496.V347359.R02.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 St Alban`s Cottage DS0000001496.V347359.R02.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&5 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 the service. Previous inspections and procedures indicate that a thorough admission process is carried out to make sure the home can meet the needs of people who move into the service. People do not have access to all the information about placements they are entitled to have. EVIDENCE: The same people have lived at the home since the last inspection so there was very little recent evidence for many aspects of this outcome group. The admission process was looked at during previous inspections and the relevant National Minimum Standards were met. The manager said staff had been introducing contracts to the people who live at the home. Keyworkers had been going through the information and sticking photographs and pictures to help people understand them. The documents still needed details of the cost of the placements and they needed signing by the people who live at the home or their representatives. Staff had started the project very recently and more information was still being made available to the people at the home. St Alban`s Cottage DS0000001496.V347359.R02.S.doc Version 5.2 Page 10 Details of how much each placement costs per week was not available in the home, although the manager obtained the cost of each placement from her line manager on the day of the inspection. St Alban`s Cottage DS0000001496.V347359.R02.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 & 9 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 the service. People’s needs have been identified but because the reviewing process has been inconsistent, changing needs have not been properly identified which could result in some care needs being overlooked. Everyone works hard to make sure people are offered choice and given opportunities to make decisions. EVIDENCE: Three people’s care records were looked at. Each plan had good information about how care needs should be met and potential risks. Files also had some photographs to help people understand how care needs should be met. For example one plan stated ‘Support me to pack my bag- I need a mobile phone, a spare jumper, my plate and spoon if I’m eating out’, another plan stated ‘please give me my purse on my lap, then I will give it to you to pay the money’. St Alban`s Cottage DS0000001496.V347359.R02.S.doc Version 5.2 Page 12 Some information in one file was incorrect; staff had written that a person had been diagnosed with a condition when this was not the case. Each file had a lot of information although some was old and out of date. The manager had identified that the files had too much information and they were difficult to follow. Care plans and assessments had not been reviewed regularly. For example some risk assessments had not been updated since January 2004 even though there had been a change in the person’s care needs. Other plans had several review dates that had been missed. Again, management had identified this shortfall. The manager had very recently introduced monthly keyworker meetings and a form to identify what had been successful and what hadn’t worked during the previous month. For example one person had been out to a café and staff had identified the person had enjoyed looking at pictures but had not enjoyed it when it got busy. These systems were in the early stages but once properly implemented they should be good tool to monitor and review care needs. People have an annual review meeting that looks at what they have done during the previous year and what they would like to do. One person had not had a review. Two people had a review but minutes were available from only one of the reviews. Daily records confirmed that care plans were being followed and people had engaged in activities that were recommended in their plans of care. Staff provided very specific details about the people who live at the home and how they looked after them. These were consistent with what had been recorded in care plans and assessments. Two surveys from people who live at the home, which were completed with the help of staff said yes, we are involved in making decisions about the home, one said sometimes. The AQAA states the Way We Work and Developing The Way We Work training is provided for staff members to equip them with the tools to drive forward person centred thinking and approaches. The keyworker system ensures that the people they support can work with a member of staff to co-ordinate and move forward their life plans and goals. On arrival at the home, a person who lives at the home answered the door, with staff support. St Alban`s Cottage DS0000001496.V347359.R02.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, 14, 15, 16 & 17 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service have a varied and fulfilling lifestyle that is based on their wishes and individual needs. EVIDENCE: Interaction between people who live at the home and staff was observed. Staff involved people in meal preparation and explained what they were doing. People at the home seemed happy and there was a good atmosphere with some lively banter. People who live at the home completed surveys with the help of staff. Surveys were positive about the care they receive. The following are a sample of their responses and comments: • We like living at the home DS0000001496.V347359.R02.S.doc Version 5.2 Page 14 St Alban`s Cottage • • • • • We feel well cared for Our privacy is respected We like the food Sometimes, there are good activities Two surveys said our privacy is respected, one said sometimes. One relative survey was received. This was very positive and said the home always meets the needs of the person, they are always kept up to date with important issues and the home always gives the support they expect. Under the ‘what do they do well section, it said the home do very well for the people they care for, and under the section how can they improve they wrote ‘ I don’t think it can be improved …as it’s the best it ever could be’. The daily records for two people, covering a four-week period, were looked at. There was evidence that people had an active lifestyle, family contact, and health appointments. Recreational activities included manicures, foot massage, BBQ, going out to a park and for walks, trips to shopping centres and an outing to The Deep. The home has a vehicle and people at the home make a financial contribution. The manager was unable to confirm how much each person paid per week. Only one staff member can drive the vehicle. The transport record was looked at and the vehicle had only been used twice over the last three weeks. There was evidence in the financial records that people were also paying for taxis. When asked what the home does well, staff said they are good at involving people in daily tasks and making sure people go out regularly. Staff said they thought everyone who lives at the home had a good quality of life. Two weeks menus were looked at and these were varied and nutritious. Staff said they were responsible for devising weekly menus, which are based on people’s preferences. They said they use pictures/photographs of food and a list of likes and dislikes to aid people with choice. St Alban`s Cottage DS0000001496.V347359.R02.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 & 20 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 the service. People’s healthcare needs are addressed but the lack of written evidence could result in healthcare needs being overlooked. Unsafe medication practices put people at potential risk. EVIDENCE: One healthcare survey was received and this was very positive. It said individual’s healthcare needs are always met and staff have done everything to make sure they have a good quality of life. The care service always respects individual’s privacy and dignity and staff seek out ways to overcome communication difficulties to make sure individuals have choice. It also said the home does well at liaising with professionals and seeking advice, and the manager has requested training and advice on healthcare needs to make sure staff knowledge was up to date. When asked what the home does well staff said people received good personal care and healthcare. St Alban`s Cottage DS0000001496.V347359.R02.S.doc Version 5.2 Page 16 Daily records stated that people had attended recent healthcare appointments. Separate healthcare records were in the files to enable staff to monitor when people had attended appointments but most of these were not up to date. For example one person had seen a dietician at the beginning of August 2007 but the healthcare record stated their last appointment was August 2006; a person had seen a language and speech therapist in July 2007 and their health record stated the last appointment was March 2004. Details of GP appointments were recorded on the separate healthcare records and this included the reason for the visit and the advice given. The inconsistencies in recording makes it difficult to monitor whether healthcare needs have been met. Individual weight records were maintained. One person had lost weight; this had been closely monitored and a dietician had helped devise a more appropriate diet. Medication and medication records were looked at and the amount of medication and the records corresponded. Medication storage was looked at and the medication was well organised. Incident reports stated that three medication errors were made between 7th July 2007 and 23rd August 2007. There was no information about action that was taken to prevent similar incidents occurring again, although the manager said they had changed the location where medication was administered. It is important to document this on incident reports and in care plans and risk assessments. Failure to report events to the Commission has been documented under the management and administration section of this report. St Alban`s Cottage DS0000001496.V347359.R02.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 & 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 the service. Complaints procedures are in place and people know who to talk to if they are unhappy. However, a lack of staff training in adult protection puts people living at the home at potential risk. EVIDENCE: Surveys from people who live at the home, which had been completed with the help of staff, said they felt safe at the home. Two surveys said they know who to talk to if they are unhappy, one said sometimes. Staff said they were comfortable discussing concerns with the manager and were confident she would deal with things appropriately. The manager talked about how she had dealt with a recent concern that had been raised. This had been managed well and appropriate action had been taken to address the problem. The home has a complaints procedure but there was no complaints record. The manager said they were going to look at developing systems that enabled people to raise concerns. Personal allowance records were looked at. All financial transactions were recorded and receipts were obtained for any purchases made. Two people’s St Alban`s Cottage DS0000001496.V347359.R02.S.doc Version 5.2 Page 18 monies were counted and the amount corresponded with the amount on the balance sheet. People who live at the home have bank accounts but one staff member is named on the accounts as the ‘Trustee for United Response’ and is the sole signatory for withdrawing money. Banking records were looked at and these corresponded with the homes record; withdrawals are clearly audited. However, access to money should not rely on one staff member The AQAA stated there are sixteen staff employed at the home. Out of the sixteen only two people had completed adult protection training; four people were booked to attend training between August and December. When dealing with adult protection issues the organisation’s safeguarding procedure stated ‘act in accordance with local procedures’. However, a copy of the local procedure and contact details were not available in the home. St Alban`s Cottage DS0000001496.V347359.R02.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, 26, 27,28, 29 & 30 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 the service. The home is pleasant and people who live there are comfortable in their surroundings. Maintenance work is needed to make sure that people live in a clean and hygienic environment. EVIDENCE: A tour of the building was carried out. Communal areas, bathrooms and bedrooms were visited. The home was clean and tidy and there were no odours. People who live at the home used all communal areas. Bedrooms were very personal, and careful consideration has been given to the décor to ensure it reflects the preferences of the people who live there. Each room had photographs, pictures and personal items. A lot of different equipment was available to help maintain skills and promote independence. St Alban`s Cottage DS0000001496.V347359.R02.S.doc Version 5.2 Page 20 Since the last inspection several internal doors have been fitted with magnetic door locks which enable people to have freer access around the home One bedroom had silver tape covering electrical sockets just above the bed head. The manager said this was because the person played with the sockets. This looked unsightly and should only be used as a short-term solution. The furnishings, carpets, and furniture were good quality and generally the home was decorated to a good standard although there were some problems with the bathrooms. The home has one shower room and one bathroom. Both rooms needed attention because some surfaces were not readily cleanable therefore they were not hygienic. Paintwork was flaking on the boxing around pipe work and some woodwork was damaged. A radiator guard was rusty. There was a build up of lime scale around the shower and the shower base was very difficult to clean. Staff said sometimes there was an offensive odour from the shower drain and the kitchen sink. The flooring had come away around the bath and the toilet. One toilet did not have a toilet seat; this was noted on the 15th August but had not been repaired at the time of the inspection; eight days after it was first reported. There was a supply of disposable gloves, wipes, anti bacterial hand wash and paper towels throughout the home. The laundry had an industrial washer with a sluicing facility and a dryer. St Alban`s Cottage DS0000001496.V347359.R02.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, 35 & 36 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 the service. People at the home are supported by a caring staff team. Staff have not been equipped with the knowledge and skills to carry out safe working practices. This could result in practices that do not protect people living and working at the home. EVIDENCE: Two surveys from people who live at the home, which were completed with the help of staff said yes, the staff treat us well, one said staff sometimes treat us well Since the last inspection a staff handover has been introduced, which includes walking around the building to check everything is ok. Staff said this helped remind them to complete tasks. Staff meetings are held every month. Staff said they received regular supervision. St Alban`s Cottage DS0000001496.V347359.R02.S.doc Version 5.2 Page 22 A shift leader is identified for each shift; they are responsible for finances and administering medication. This is recorded on the staff rota. The organisation has introduced keyworker training. Two staff had attended and others were waiting to attend. The manager said the training gave people a better understanding of the role and responsibilities of a keyworker. The organisation has recently introduced a competency framework, which provides specific areas of competency for different staff roles. The framework is used during the recruitment and induction process. Candidates who recently attended an interview were asked questions that related to the framework. This is good practice and helps staff have a better understanding of their roles and responsibilities. The manager said they had identified that some staff training was not up to date and they had arranged for staff to attend training between August and December. A training matrix was looked at and this confirmed that there were significant gaps. Several staff had not completed mandatory training such as first aid and food hygiene. This should be addressed as soon as possible because there will be shifts when all staff on duty have not completed their basic training. For example staff will be preparing and cooking food even though they do not have a food hygiene certificate. The AQAA stated 60 of care staff have achieved or are working towards National Vocational Qualification (NVQ) level 2 or above. Staff were being recruited at the time of the inspection. Two people had returned for a second interview, which involved spending time with people who live at the home. Recruitment records were looked at for two people who recently started working at the home. All the information that is required before a person can start work had been obtained. St Alban`s Cottage DS0000001496.V347359.R02.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, 41 & 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 the service. The home is well managed but the absence of a registered manager leaves the service vulnerable putting people at risk because it does not have a person who is accountable for managing the service on a day to day basis. EVIDENCE: The manager has managed the home Since March 2007. She had a good understanding of her management responsibilities and was fully aware of the areas that need developing to meet the National Minimum Standards and had clear plans of how they could achieve this. She talked about consultation and involving people who live and work at the home. The manager is hoping to commence the registered manager’s award in October 2007. St Alban`s Cottage DS0000001496.V347359.R02.S.doc Version 5.2 Page 24 Staff said the manager was ‘a good manager’ and was approachable and encouraged people to put forward ideas. Staff also said United Response was a good organisation to work for. The home has not had a registered manager for over two years. The manager was in the process of completing her application and anticipated that she would submit it before the end of September 2007. The home will benefit from having a registered manager to provide the home with continuity and consistency. As stated under the personal and healthcare support section, there had been three medication errors, which could affect the health and welfare of people who live at the home. These events should have been reported to the Commission under Regulation 37 of the Care Standards Act. Guidance on reporting events was sent to the manager following the inspection. The AQAA states relevant policies and procedures were in place. It also states equipment has been serviced or tested as recommended by the manufacturer or regulatory body. Electrical circuits were tested in October 2006, Fire equipment was serviced in May 2007 and gas appliances were tested in October 2006. There are different quality assurance systems in place. The manager said she thought these were effective and had highlighted many of the shortfalls that had been identified at the inspection. St Alban`s Cottage DS0000001496.V347359.R02.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 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 4 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 3 X 2 3 X St Alban`s Cottage DS0000001496.V347359.R02.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 YA5 Regulation 5 Requirement The registered person must ensure people have a statement of terms and conditions. A record of the current range of fees must kept in the home. This will make sure people have access to information about their placement. People must have an update service user plan that identifies their social, personal and healthcare needs. This will make sure people’s needs are met. Risks must be assessed and reviewed to make sure people are safe. The transport arrangements must be reviewed to make sure charges to service users are recorded, equitable and value for money. Healthcare records must be appropriately maintained to make sure people’s healthcare needs are properly met. Staff must make sure medication is administered properly to make sure people receive the right amount of medication. A complaints record must be DS0000001496.V347359.R02.S.doc Timescale for action 30/09/07 2 YA6 15 30/11/07 3 4 YA9 YA13 13 17 12 16 12 30/11/07 30/11/07 5 YA19 30/09/07 6 YA20 13 30/09/07 7 YA22 22 30/11/07 Page 27 St Alban`s Cottage Version 5.2 8 YA23 13 9 23 maintained so the number and nature of reports can be properly monitored. All staff must be appropriately trained to make sure they understand safeguarding adults policies and procedures. The toilet seat must be repaired to make sure people can be comfortable when using the toilet 31/10/07 30/09/07 YA24 23 13 10 11 YA30 YA35 12 YA37 14 YA41 The tape covering the electric sockets in one bedroom should not be used and a more appropriate method used to make sure the person is safe. 16 Surfaces in bathrooms must be readily cleanable to prevent the spread of infection. 13 Staff must complete training that 16 equips them with the knowledge and skills in safe working practice topics. CSA The acting manager must make Section 11 application to be registered. To make sure the home has a person who is responsible for the day to day running and is accountable to the Commission. 37 The Commission must be notified of any event that affects the health or well being of any person living at the home. 31/10/07 31/10/07 30/11/07 30/09/07 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. Refer to Standard YA23 Good Practice Recommendations Where staff are responsible for withdrawing money from bank accounts, more than one staff member should be able to withdraw cash to make sure people can access DS0000001496.V347359.R02.S.doc Version 5.2 Page 28 St Alban`s Cottage 2. YA37 money when it is required. The manager must be suitably qualified to make sure they have the knowledge and skills to manage the service. St Alban`s Cottage DS0000001496.V347359.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 St Alban`s Cottage DS0000001496.V347359.R02.S.doc Version 5.2 Page 30 - 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. 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