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Inspection on 17/08/06 for St Mark`s Road Care Home - Block B

Also see our care home review for St Mark`s Road Care Home - Block B for more information

This inspection was carried out on 17th August 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home operates on principles that enable people who live there to be selfmanaging and as independent as they can be within the limits placed upon them by their disability; for the majority of current residents the latter is quite high. Those individuals that are able to verbalise are routinely consulted on all aspects of their daily living, and about the running of the home. Individuals are supported to access community and recreational facilities of their choice, and structured weekly activities have been developed for everybody at the home. The staff team has been supported and complimented by families for the positive impact they have had on the lives of people living there. The staff team are committed to working towards making people as independent as possible and ensuring they have fulfilling lives. The staff team have an awareness of individual`s needs and aspirations, and the records reflect this. The home is spacious and well laid out, enabling individuals to move freely around the environment, with or without staff help. The home is well decorated and maintained, and is small enough to retain a homely atmosphere. Individual`s bedrooms are large, with modern and suitable furniture and equipment, and reflect individual`s interests and personalities. The home has been particularly well equipped with aids and adaptations that provide assistance with mobility and handling tasks.

What has improved since the last inspection?

The standard of documentation in relation to assessing needs and planning care has been improved and the care that is provided is based on up to date information. Some work has also been carried out to improve the records in relation to the recording of complaints to the home.

CARE HOME ADULTS 18-65 26 St Mark`s Road Care Home - Block B 26 St Mark`s Road Derby DE21 6AH Lead Inspector Brian Marks Unannounced Inspection 17th August 2006 9:15 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.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 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.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. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 26 St Mark’s Road Care Home - Block B Address 26 St Mark’s Road Derby DE21 6AH 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) 01332 294466 01332 242449 karen.bridge@robinia.co.uk The Robinia Group PLC Karen Mary Bridge Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: Robinia Care Group is the responsible provider for 26 St Marks Road. The home is located on the same site as another home owned by this organisation and the same Registered Manager is responsible for both homes. The home was purpose built to a high standard and registered in 2005, to provide personal care and accommodation for up to 8 people in the category of learning disability, aged between 18 and 65 years of age. At the present time the group of people living at this home are of an older age group than its linked home, so that between them they provide age appropriate services. The home is situated in Chaddesden just outside Derby City centre and is close to local amenities. A car park is available at the front of the premises and a garden at the rear. The home provides a spacious environment with all rooms being single with en-suite shower facilities. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place at the home over a period of 6 hours in one day. Additionally, time was spent in preparation for the visit, looking at previous reports and other relevant documents and preparing a structured plan for the inspection. At the home, apart from examining documents, care files and records, time was spent speaking to the area manager of the company, who was present for part of the visit, and the team leader on the day shift who was in charge of the home. Additionally 6 of the staff working at the home at the time were interviewed. The care records of 3 people who live at the home were examined but, due to their level of learning disability, only 1 was able to speak to the inspector about life at the home. The residents present during the inspection were observed interacting with each other and being cared for by the staff on duty. Before the inspection written comments were also received from professionals in the local Learning Disability Service about specific aspects of care at the home. The registered manager was on extended sick leave during the inspection. What the service does well: The home operates on principles that enable people who live there to be selfmanaging and as independent as they can be within the limits placed upon them by their disability; for the majority of current residents the latter is quite high. Those individuals that are able to verbalise are routinely consulted on all aspects of their daily living, and about the running of the home. Individuals are supported to access community and recreational facilities of their choice, and structured weekly activities have been developed for everybody at the home. The staff team has been supported and complimented by families for the positive impact they have had on the lives of people living there. The staff team are committed to working towards making people as independent as possible and ensuring they have fulfilling lives. The staff team have an awareness of individual’s needs and aspirations, and the records reflect this. The home is spacious and well laid out, enabling individuals to move freely around the environment, with or without staff help. The home is well decorated and maintained, and is small enough to retain a homely atmosphere. Individual’s bedrooms are large, with modern and suitable furniture and equipment, and reflect individual’s interests and personalities. The home has been particularly well equipped with aids and adaptations that provide assistance with mobility and handling tasks. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.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. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.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 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The support and care needs of individuals are comprehensively assessed to ensure that their aspirations are planned for and that the home is right for them. EVIDENCE: The care files of 3 of the residents were examined in detail and all contained comprehensive Community Care Assessments, prepared by a Local Authority professional, as well as wide-ranging assessments from a number of professionals from local learning disability teams, hospital or other residential placements. The home’s manager had also carried out a ‘pre-placement assessment’ that is more focussed on the person’s needs in relation to functioning within the setting of the home itself. All of this written material allowed for the care and support being given to the people living at the home to be based on up to date information, and for the right decisions to be made in their lives. Before they came to live at the home prospective residents visited and stayed overnight, to give them a realistic idea of what they could expect if they chose to move in. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents care needs have been assessed, risk factors identified and care planned in ways that reflect their individual preferences and abilities. This follows direct consultation, or staff judgements where communication is difficult. However, there are times when plans for care are not being followed and outside professional advice not being heeded, which could put residents at risk. EVIDENCE: All of the files examined contain a service plan that has been developed from the pre-admission information and included all the key aspects of personal and healthcare support specific to those individuals. The support arrangements are set out as a series of ‘Aims and Objectives’, which are based on the individual’s needs and aspirations. The individual’s key worker is responsible for completing progress reports on a monthly basis for each objective, and this was indicated in each section, with revisions where necessary. However written comments from local professionals indicated a number of instances where there had been failures to follow specific aspects of the personal plans of individuals, previously agreed at care plan meetings or following their 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 10 assessment work. Whilst these had not resulted in harm being caused to residents they did place them at risk and demonstrated situations where staff were not acting in fully professional ways. Both files contained a variety of assessments of how the hazards of daily living affected individuals (risk assessments); these indicated key areas of concern and ways in which staff could minimise or eliminate any problems arising from these risks. However the assessment of mobility and handling problems had not been separated out from the body of the generic risk assessments and, as this is a key area for the majority of people living at the home, doing so will highlight this and make for safer and more consistent patterns of support. From discussions and observations made by the inspector it was evident that individuals are actively encouraged to be self-managing and independent in their lives and observations confirmed that service users are consulted on a daily basis concerning aspects of their routines. Communication skills are important in this area and staff have developed ways of understanding individual expressions of choice over time, a particularly difficult area of work where verbal skills are absent. They use observations, made over time, of individuals’ body language, gestures, sounds and other patterns, which help them to understand likes and dislikes. Staff also stated that it is easier to interpret negative choices being made than it is for positive choices. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Individuals living in the home have varied daily routines that give them opportunities and experiences that promote independent living skills and wider social contacts. Contact with family and friends is promoted and supported. EVIDENCE: A weekly planner of activities is completed for all individuals living in the home, and each individual has a structured daily plan. At the time of the inspection 2 residents went out on a shopping trip to Derby, using public transport, although a minibus is provided for longer trips. There is an activities coordinator in post who shares her time with the associated house next door and in discussion she explained her plans to extend the current range of activities to ‘stretch’ the residents and offer the new opportunities for development and enjoyment. At the present time she is involved in accessing facilities such as college and day centres for the people living at the home and weekly visits by the ‘Pets as Therapy’ scheme. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 12 Discussion and observation confirmed that the daily routines of the home are flexible and promote individual’s independence, choice, and freedom of movement, in accordance with their support needs. Additionally contact with family and friends are encouraged by the staff team, and care records confirmed this. Discussion with staff on duty and examination of kitchen records, confirmed that individuals are given a healthy, cosmopolitan diet. This is aimed to meet with individual choices and requirements, and also includes special diets such as fully thickened drinks and weight management. Individuals are supported to choose their meal on a daily basis and 2 involve themselves with kitchen activities in a limited way. The main meal of the day is in the evening and on the day of the inspection the popular takeaway option was being planned; all people living at the home are encouraged to eat together. Food shopping by staff is done at local supermarkets and there were good stocks in the kitchen. Menus are planned in advance on a weekly basis and written records of food served are retained to make sure that a variety of meals are prepared. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The personal and health needs of residents are dealt with in a satisfactory way, although in some instances outside professional advice is not being heeded, and recommendations regarding medicines administration, made at the last inspection, have not been followed, which could put residents at risk. EVIDENCE: The support plans in place are individual to each person and indicate how each person is to be helped with their personal care needs and assistance with mobility. As all of the current resident group use a wheelchair for all or part of their daily lives, the latter is a substantial issue at the home. Individual cultural requirements are also recorded and implemented as part of their support plan, although there are currently no residents at the home who are from a minority ethnic background. People living at the home are supported by the staff team to receive health care both at the home and at outside clinics – a District Nurse visited during the inspection – and information about the outcomes and any required action is recorded in the medical files for that person. As noted in a previous section, the comments from local professionals apply to this section as well and demonstrated situations where staff were not acting in fully professional ways. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 14 There are no residents administering their medication themselves and the team leader on shift takes responsibility for this activity; records examined and staff spoken to confirm that appropriate training had been received from the home’s pharmacist. Storage arrangements and stock levels were satisfactory, as were records of drug administration, apart from a number of instances where handwritten instructions about changes in administration had not been signed and dated and the use of code letters did not have attached explanations of their meaning. These recommendations were also made at the last inspection and could lead to errors on medicines practice. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Satisfactory complaints and adult protection procedures are in place in order to safeguard service users; there remains a shortfall in the provision of staff training about the latter, which does not enhance the safety of residents. EVIDENCE: A complaints procedure and recording system are in place and an accessible procedure displayed within the home. The written records indicated a number of ‘informal’ – all dealt with appropriately – and 1 more serious complaint from a resident’s parent. The latter has been fully investigated by the home’s line management but a final outcome had not been reached at the time of the inspection. The parent company’s Vulnerable Adults policy was in place, along with a copy of the local procedures. Both management and the staff all have an awareness of these procedures and their responsibilities in respect of allegations being made. However, records indicated that not all staff had had formal instruction or training in the issue, as the law requires. There have been no reports made under these procedures since the home became operational. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The home is equipped, furnished and maintained to a high standard and offers homely and spacious facilities for individuals to enjoy. EVIDENCE: A brief tour of the building indicated good standards of decoration and furnishing and that it is small enough to retain a homely atmosphere. Visits to some of the bedrooms indicated that private space is respected and they are personalised to reflect the interests and preferences of the individual. All bedrooms are single with a ceiling-tracking hoist to assist with safe moving and handling, which also leads into the en-suite shower and toilet facilities. Other aids and adaptations to assist with individual mobility are also provided including specialist baths, mobile hoists and special chairs and furniture. There is also a sensory room, which is well used by some of the residents for both relaxation and fun, and this was being used during the morning of the inspection. The kitchen area is accessible for individuals who use wheelchairs, and an accessible worktop is provided enabling individuals to make their own meals 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 17 and drinks if they wish to. The garden and outside areas are all accessible for wheelchair users and the home is currently developing these. Standards of cleanliness and hygiene around the home are high, the laundry facilities are domestic in style and all residents were appropriately dressed in clean clothing on the day of the inspection. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The deployment and numbers of staff are satisfactory to meet the needs of the people living at the home but there are shortfalls in the process of staff recruitment and the staff training programme, which may put residents at risk. EVIDENCE: The staffing levels provided at the home are high with 5 staff being in place on each day shift; this enables some one-to-one as well as group support both inside and outside the home. Additional staff members can be on duty to provide support for any planned activities or when the needs of the individuals require additional support. The staff spoken to showed a good awareness of the support needs of the people living at the home, and were observed having warm, friendly and professional interactions with individual residents. Two staff files were looked at, both being for staff who had recently been appointed. They indicated a thorough recruitment and selection procedure being followed, designed by the parent company, but neither had copies of 2 written references being received and 1 was missing photographic and documentary proof of identity, as required by law. Some of the staff spoken to confirmed their access to regular training and development opportunities, but records indicated particular shortfalls in the provision of training in the key areas of adult protection (see above), the induction programme for new staff 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 19 and the key health and safety subjects of safe food handling and safe manual handling. The latter is of particular importance in view of the number of the current resident group who spend all or part of their time in a wheelchair. Additionally training and development activities aimed at giving staff a clear understanding of the complex needs of people who may come to live at the home had not been given and the target for achievement in the National Vocational Qualification (NVQ) had not been met. These shortfalls in an important aspect of the home’s operation leave the staff group under equipped to do their jobs. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is managed in the best interests of the individuals living there and the parent company supports the home’s manager to operate it successfully. EVIDENCE: The Registered Manager is currently undertaking an NVQ level 4 in management and care and has responsibility for the two homes located on the same site. She is supported by a deputy manager and each home has 3 team leaders so that a senior person is on duty at the home on all shifts. Reports were on file that indicated that a representative from the organisation regularly undertakes visits to the home in accordance with the requirements of regulation 26 and to support the manager. At the time of this inspection both the manager and deputy manager had been away from the home for some weeks and this will soon start to have a detrimental effect on the running of the home, although the area manager for the owners has become routinely based at the home to compensate for the shortfall. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 21 The home now has a full occupancy and the area manager described a quality assurance system that the parent company is about to introduce at the home that will involve a number of audits by managers from outside the home. This will allow for the completion of a development plan of what is to be achieved in the next 12 months. Surveys of the views of the people living at the home, their families and representatives will also be included in this process, so that everybody involved in the home will have the opportunity to comment about its standards and quality of care. The Health and Safety standards in the home are satisfactory and most are still in date as the home has been in operation for just 12 months. The staff undertake health and safety audits of the building and complete records and there was evidence to support that the required fire tests and checks are undertaken and records maintained. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 22 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 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 4 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 3 X X 3 X 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 YA6 YA18 YA19 Regulation 15(1) Requirement All aspects of resident care plans must be followed and the outcomes fully recorded, including the outcomes of multi disciplinary assessments carried out by outside professionals. Where there is difficulty in completing actions from care plans these must be reviewed and revised following further outside consultation where appropriate. Handwritten instructions on the MAR sheets, including those that relate to changes directed by the GP, must be clearly recorded, dated and countersigned by two people. (Previous timescale of 01/04/06 not met). The Registered Persons must ensure that the staff team use the appropriate codes to record why medication has not been administered. (Previous timescale of 01/04/06 not met). All staff must receive training/instruction in their responsibilities under local DS0000063062.V315657.R01.S.doc Timescale for action 30/09/06 2. YA20 13(2) 30/09/06 3. YA20 13 (2) 30/09/06 4. YA23 13(6) 30/11/06 26 St Mark`s Road Care Home - Block B Version 5.2 Page 24 5. YA34 19(1) Schedule 2 interagency procedures for the protection of vulnerable adults. Staff recruitment files must obtain evidence that a full employment history, 2 written references and proof of identity have been obtained for newly employed staff. 31/10/06 6. YA35 18(1) 7. YA35 18(1) 8. YA37 12(1) All newly appointed staff must 30/09/06 receive a programme of induction training at the point of commencing employment that equips them to work with the people living at the home. This must specifically include the subjects of safe moving and handling of people, the use of specialised equipment and safe food handling. Other staff who have not received training in these subjects must do so by this due date. The Registered Person or their 31/08/06 representative must forward an action plan in relation of the achievement of requirement 6 by this due date. The management arrangements 30/09/06 of the home must be quickly resolved to maintain the standards of care of the residents. 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 25 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 YA6 Good Practice Recommendations All documentation completed for services users should be signed and dated and completed in full, and individuals or their representatives should be consulted and included in the development of their plan, where appropriate. The Personal Care Plan document should be completed for all people living at the home. The home’s management should review all care records to ensure that they are as concise as possible and present as a useful working tool rather than a depository of old information. A Moving and Handling risk assessment should be completed separately from other risk assessments in order to make it clear what support individuals require from staff. The target for achievement in the training of staff at NVQ level 2 should be met within 18 months of the home’s commencement. Staff should receive training that raises their awareness of the various and complex needs of the people who might live at the home. The home’s managers and owners should implement the company’s Quality Assurance system into the home to assist with its continued development. 2. 3. YA6 YA6 4. YA9 5. 6 7. YA32 YA35 YA39 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 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 26 St Mark`s Road Care Home - Block B DS0000063062.V315657.R01.S.doc Version 5.2 Page 27 - 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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