Inspection on 14/11/06 for St Philips Close

This inspection was carried out on 14th November 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Philips Close 03/10/07

St Philips Close 23/05/06

St Philips Close 23/11/05

St Philips Close 04/05/05

St Philips Close 02/11/04

St Philips Close 18/05/04

St Philips Close 25/11/03

St Philips Close 19/08/03

St Philips Close 09/10/02

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

CARE HOME ADULTS 18-65 St Philips Close 1 St Philips Close Middleton Leeds West Yorkshire LS10 3TR Lead Inspector Dawn Navesey Key Unannounced Inspection 14th November 2006 09:30 DS0000001500.V317169.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 DS0000001500.V317169.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. DS0000001500.V317169.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Philips Close Address 1 St Philips Close Middleton Leeds West Yorkshire LS10 3TR 0113 277 8069 0113 2778069 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) londonroad@tiscali.co.uk Milbury Care Services Limited Care Home 4 Category(ies) of Learning disability (4) registration, with number of places DS0000001500.V317169.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd May 2006 Brief Description of the Service: 1 St Philips Close is a purpose built bungalow located in a residential area of Middleton close to local amenities and public transport routes. There is roadside parking to the front of the home. There are well maintained gardens to the rear of the property that are accessible to service users. The home is registered to provide personal care for four people with learning disabilities. The accommodation includes four single bedrooms, a communal lounge, dining room, a communal bathroom and toilet, a domestic style kitchen and separate laundry room. The current scale of charges at the home is £8,730.60 per annum. Additional charges are made for toiletries, magazines, outings, activities and taxis for college. DS0000001500.V317169.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The last key inspection was carried out on 23 May 2006. To monitor the home’s progress in meeting the requirements of the key inspection a random visit took place on 31 August 2006. There have been no further visits until this unannounced key inspection, which was carried out by two inspectors between 9-30am and 5pm. The purpose of this key inspection was to monitor progress in meeting the requirements and recommendations made at both the last key and random visit, and to make sure the home was providing a good standard of care for the people living there. The people who live at the home prefer the term service user; therefore this will be used throughout the report. The methods used at this inspection included looking at care records, observing working practices and talking to service users and staff. Most of the service users have complex needs and discussion with them was limited, as they do not use verbal communication. Information gained from a preinspection questionnaire and the home’s service history records were also used. There were no visitors to the home on the day of the visit. Surveys and comment cards were sent to service users, their relatives and a number of visiting professionals to the home, asking for their views about the home. Three of these have been returned. This information has also been used in the preparation of this report. Feedback was given to the senior support worker at the end of the day. Requirements and recommendations made during this visit can be found at the end of the report. Thank you to everyone for the pre-inspection information, returned comment cards and for the hospitality and assistance on the day of the visit. DS0000001500.V317169.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The manager and staff must continue to work on the service users’ care plans to make sure that they are detailed and cover all the needs of service users. The manager and staff must make sure that service users are provided with activity and stimulation suitable to their wishes and needs. The home must address a number of training issues. The manager must make sure that all staff are trained in current practice regarding moving and handling so that this is done safely. Staff must also receive training in the specialist needs of service users, such as epilepsy and dementia. DS0000001500.V317169.R01.S.doc Version 5.2 Page 7 Nutritional assessments must be carried out for service users at risk from weight loss. A care plan must then be put in place to make sure any action from the assessment is followed. The manager must make sure that accident reports are fully completed with details of the accident and any follow up or outcome of the accident. The manager must make sure that staff’s records are available for inspection so that recruitment records can be checked. 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. DS0000001500.V317169.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000001500.V317169.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users or their representatives have sufficient information available to make sure they can make a choice about the home. Service users have a pre admission assessment carried out to make sure the home can meet their needs. EVIDENCE: The Statement Of Purpose and Service User Guide have been produced in an easy read format, using large print and pictures. These are both kept on display in the entrance hall of the home where families and visitors can have access to them. It would be good practice to make sure relatives or representatives of service users are given a copy of these. The manager has been planning to produce the Service User Guide with photographs to make it more easily understood by service users who have complex needs. This has not been done as yet. DS0000001500.V317169.R01.S.doc Version 5.2 Page 10 The terms and conditions showing costs to service users are now included in the Service User Guide. An easy read complaints procedure is also in this guide. Contracts are mainly signed on behalf of service users. It is not clear whether the signature has been made by a relative of the service user, or a representative from the organisation. Service users’ needs had been assessed before they moved in to the home. Some of the assessment information had not been dated or signed. This made it difficult to see who had completed them and when. It was not clear if the information was current. A service user said he was happy at the home, saying “I like it here.” DS0000001500.V317169.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans have improved but do not always provide clear, detailed instruction on how all service users’ needs will be met. Service users are involved in the day- to- day running of the home and can have influence over what happens there. EVIDENCE: Some good work has been done on improving the care plans and risk assessments. Each service user has a summary of their needs at the front of their care plan. These are person centred and focus on the person as an individual. They are written in the first person. These summaries would benefit from saying they need to be read alongside the care plans. This would make sure that staff know, in detail, the level of care and support to be given to meet service users needs. DS0000001500.V317169.R01.S.doc Version 5.2 Page 12 Most of the care plans have detailed and specific instructions for staff. The plans are current and staff are able to accurately describe the care they give. However, some care plans need more explanation. For example, a plan relating to pressure area care said that a pressure-relieving mattress was to be “checked regularly”. It did not say how this was to be done. A plan to assist a service user to walk said to give “minimum support”. This information is vague and could lead to important needs being missed. There needs to be specific instruction on how this support is given. Some staff, however, have good knowledge of the service users’ needs and it is obvious they know them well. Some care plans were not linked to the assessment of service users’ needs. A service user who had epilepsy had no care plan for how to manage their epilepsy. A service user who is registered blind had no plans to show how he is supported with his visual impairment. Another service user who has needs related to dementia has nothing in their plan to show how these needs are met. There is some excellent information in the pen pictures and communication diaries of service users. This information needs to be linked to the care plans. For example, the pen picture said a service user likes bubble bath in the bath. The bathing care plan did not mention using bubble bath. Another example was that the communication diary referred to some guidelines on behaviour for a service user. These were not in the care plan. The service users have two care files, with different pieces of information in them. This system can be confusing and could lead to care needs being overlooked. Service users’ risk assessments were up to date and have been reviewed. However, there is no information on how they have been reviewed and what has been taken into account. Care plans have also been reviewed, every six months, in this way. They do not give clear details of how the plan is still effective or an overview of care during those six months. They just state the date they were reviewed and are signed by the staff member. Formal reviews have now taken place for some service users. A relative said they were disappointed that no review had taken place for some time and felt because of this they are sometimes “kept in the dark” about their relative’s care. Key workers do a monthly review with service users too. This information would be good to use when reviewing care plans and risk assessments. It would also be good practice to involve relatives more in this. Care plans are mainly focussed on physical and emotional care needs. It is disappointing that there are no plans for recreation, hobbies or leisure interests of service users. Staff could, however, talk about what people liked doing in their leisure time. DS0000001500.V317169.R01.S.doc Version 5.2 Page 13 Staff said that service users’ families had been involved in the drawing up of the care plans. They said they asked them for information on how their relative liked to be cared for. A relative who returned a comment card said that they were consulted about the care of their relative. Staff gave examples of how service users are involved in the day- to -day running of the home. They said that wherever possible, service users choose what to do, what to eat and when to get up or go to bed. Staff said they spend time getting to know service users so that they can get to know how they show their preferences. DS0000001500.V317169.R01.S.doc Version 5.2 Page 14 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 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In the main, service users have varied and regular activity. Staff encourage and support service users to maintain relationships with their families and within the community. Service users benefit from a varied, healthy and balanced diet. EVIDENCE: Service users are involved in various activities each week. This ranges from college courses, Gateway clubs, shopping and walks out. Staff said they feel limited at times by the staffing numbers in that there are only two staff on shift with the four service users. They said this means it is difficult to get out DS0000001500.V317169.R01.S.doc Version 5.2 Page 15 on one to one activities. Staff did say however, that the manager would try to make sure there are more staff on for special events or occasions such as birthdays and Christmas shopping. One service user had recently celebrated a special birthday with a party at the home. The family of this service user had said how pleased they were with the organisation of this party. Activity is recorded in the service users daily records. Records showed that some service users do not have much stimulating activity while in the house. During the morning of the visit, there was very little interaction with service users other than when personal care was being given. The home was very quiet with little stimulation. Service users do not have care or support plans in place to show how to support them with activity or leisure. This needs to be addressed so that leisure and activity needs are properly met. An activity was arranged in the afternoon of the visit. A musician has been found who will provide music and sing-a-long on a fortnightly basis. Service users and staff all joined in with this. It appeared to be enjoyed by all. Staff explained how service users are part of their local community. They attend local church bazaars, harvest festivals and maypole dancing. Service users also use local shops and attend events such as brass band and rugby matches in the local park. The home does not have its own transport so taxis and buses are used for getting out and about. Some service users have had an annual holiday. Others are waiting to be arranged. One service user said “I went to Blackpool for holidays and saw Shirley Bassey, I enjoyed it.” Staff offered choices to service users and acted on their wishes. For example, a service user who wanted to listen to music was given a choice of where to listen to it. A service user who only likes cold drinks was always given a cold drink. Staff also talked about service users’ rights to privacy. For example, one staff said, when opening mail it is important to be sensitive when asking a service user if they want a letter or card to be read to them. The menus and choices of food in the home are good. The food is varied and healthy, while catering for service users preferences. Baked potatoes, with beans, cheese and ham was served at lunchtime. The evening meal was meat pie, mashed potatoes, broccoli and cabbage followed by apple pie and custard or fresh fruit. Staff said they can cook alternatives if service users do not like what is on the menu. A service user said the staff were good cooks and the food was good. Throughout the day, service users were offered a choice of drinks such as tea, coffee or juice. DS0000001500.V317169.R01.S.doc Version 5.2 Page 16 Service users were assisted with their meals where needed. Staff made sure that those who needed them had the necessary equipment, such as plate guards, to give them as much independence as possible. Service users were given support with respect and courtesy. However, there was very little social interaction between the staff and service users throughout the meal. DS0000001500.V317169.R01.S.doc Version 5.2 Page 17 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 and 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Despite some lack of documentation in the care plans, service users are mainly supported properly with their personal and health care needs. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Personal support was given to service users in a quiet and dignified way. They were supported to get dressed and to bathe in private and when they wanted to. Service users were dressed in clothes of their choosing. One service user wore his favourite rugby shirt and enjoyed talking about this. The care plans had details of service users’ preferences for bathing. For example, which toiletries they preferred and what type of shave they had. DS0000001500.V317169.R01.S.doc Version 5.2 Page 18 Some poor practice was seen in that a service user was moved using an under arm lift that should no longer be used and can cause physical injury. Service users’ moving and handling needs must be assessed to see if they need any additional equipment such as a moving and handling belt. Staff must be trained in current moving and handling practice. The care plans also had details of any health professionals that service users see. These included, GP, district nurse, dentist, specialist nurse, psychologist and chiropodist. Records are kept of any health appointments and their outcome. Staff said that they are now trying to get an optician for service users. Staff always accompany service users on all their health appointments. Service users are weighed monthly and this information is recorded. Service users who are nutritionally at risk and have been losing weight do not have plans to show staff what to do to increase the nutritional value of their food. However, their food intake is monitored and staff said the specialist community nurse assesses these records. The specialist needs of service users who have conditions such as dementia and bi-polar disease are not properly documented. Staff have received some awareness training around dementia needs but were not able to say how they put this into practice. Staff were also supporting service users who have epilepsy but had not had any training in this. Staff said they would intuitively know what to do and when to call for emergency assistance. This lack of training could lead to a risk of harm to service users. The service users’ last wishes and funeral arrangements have not been written in to their plans around ageing, illness and dying. However, staff have attended bereavement training and are planning to get this information into the plans in the future. Also, it is not clear what religion service users are, as this is not written in their care plans. The systems for medication showed much improvement. The home continues to use a monitored dosage, pre-packed system for the medicines. Senior staff are responsible for the administration of medicines and have been trained to do so. There were good ordering and checking systems in place, with a clear audit trail for any unused medication returned to the pharmacy. The abbreviations have been removed from the medication policy and the administration record sheets were checked and showed no errors. Consent for the use of homely remedies has been gained from each service users’ GP. The organisation’s homely remedies policy now needs to be updated to give staff instruction on how to record the use of homely remedies. DS0000001500.V317169.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users or their representative’s concerns are listened to and acted upon. Service users are protected from abuse by the home’s policies and procedures on adult protection. EVIDENCE: The home has a complaints procedure displayed in the entrance to the home. This has been produced in an easy words format to make it more accessible to all. A relative who returned a survey card said they did not know how to complain but had never had to make a complaint. It would be good practice to make sure that all service users or their representatives had a copy of the complaints procedure. Staff were aware of the complaints procedure and how to handle any complaints they receive. The home has not received any complaints since the last inspection. All the staff spoken to had received training on the protection of vulnerable adults. They were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. DS0000001500.V317169.R01.S.doc Version 5.2 Page 20 The home has a policy on the protection of vulnerable adults. This would benefit from having the contact details of the local adult protection unit in. A recent possible adult protection issue in the home has been investigated very thoroughly by the organisation. Service users have their own bank accounts and there are systems in place to make sure their money is protected. Good records are kept of service users’ finances and proper handovers are done between changes of staff shifts. This is good practice. DS0000001500.V317169.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment in the home is clean, safe and hygienic. EVIDENCE: The home is very nicely decorated, well furnished and homely. Service users have their own rooms, which have been decorated and furnished to suit them as individuals. One service user is about to have a “designer” bedroom makeover and is very much looking forward to this. The home is warm, clean and well set out with plenty of space for service users to move around in. There is a choice of shower room or bathroom. The bath is fitted with a hoist to assist those that need this. DS0000001500.V317169.R01.S.doc Version 5.2 Page 22 Infection control is well managed. All staff have now received training in infection control or have a date when this will be done. Staff were able to say what the infection control measures are and why this is important. Staff demonstrated good practice in infection control when assisting service users with personal care tasks. During a tour of the premises, it was noted that the hot water from some taps seemed too hot. Staff checked this with a thermometer and it was above the recommended level. This was reported to the housing association that is responsible for the building and action was taken in the home to prevent anyone being scalded by the water. Staff agreed to inform the inspector of the outcome from the housing association within three days. DS0000001500.V317169.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are competent and understand the needs of service users. Staffing levels need to be reviewed to make sure all the needs of service users are met. EVIDENCE: There are staff on duty throughout the day and night. There are usually two staff on the morning shift, two staff on the afternoon shift and one staff on the night shift. The manager oversees this home and the home next door, splitting her time between the two. A small amount of this time is supernumerary allowing her to do administration and management tasks. Staff said that the current staffing allows them to meet the needs of the service users but limits the time they have to get service users out of the house on activities. Care plans showed that some service users need two staff DS0000001500.V317169.R01.S.doc Version 5.2 Page 24 for some tasks such as bathing and dressing, which means that other service users are left unsupervised for short periods of time. Improvements have been made with staff training. All staff’s statutory training is or will be up to date by the end of this year. Staff said they were happy with the level of training they had received and felt equipped to do their job. They had recently received training on care planning and risk assessment from the home manager. The improvements with the care plans showed that this had been put into practice. 45 of the staff have now achieved an NVQ (National Vocational Qualification) level 2 or 3 in care. Two more staff are also undertaking this at the moment. Staff said that doing their NVQ had made them think more about their practice and why it is important to do things properly and consistently. All staff need training in the specialist needs of service users such as epilepsy, dementia, visual impairment and bi – polar disorder. Recruitment records were not available for inspection because only the manager has access to staff files and she was not on duty. The senior support worker from the adjoining home said that the manager had plans to give keys for the staff files to the deputy manager once they are in post and to the senior support worker in each of the homes once they have completed their probation period. This will make sure there is access to staff’s files at all times. The senior support worker said that recruitment is done properly; interviews are held, references and CRB (Criminal Record Bureau) checks are obtained prior to staff starting work and checks are made to make sure staff are eligible for work. Staff said they received regular supervision from the manager. They also said they find the manager very supportive and approachable. Team meetings take place on a regular basis. Staff said they felt there was good teamwork within the home and they feel able to contribute by making suggestions. DS0000001500.V317169.R01.S.doc Version 5.2 Page 25 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, 40 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed. Staff and residents receive good support from the manager. Overall, health, safety and welfare are promoted. EVIDENCE: The home has an experienced manager. She is currently doing her NVQ level 4 and Registered Managers Award. As mentioned in the staffing section of this report, the manager is given 20 hours administration time to oversee this home and the home next door. The rest of the time she is on shift and part of DS0000001500.V317169.R01.S.doc Version 5.2 Page 26 the staffing rota. The manager has now applied to the CSCI (Commission for Social Care Inspection) to be the registered manager. The operations manager visits the home on a monthly basis to carry out regulation 26 visits. This involves talking to service users and staff about the home. A report of these visits is made showing details of any action to be taken to improve the service. A service review is also carried out every year as part of the quality assurance system. The report from this could not be found on the day of the visit and staff were not aware of the review. Staff carry out weekly health and safety checks around the home such as fire alarms, water temperatures and look for any repairs that are needed. Health and safety records are fairly well maintained. Environmental risk assessments are completed and up to date. Accident reports are now more detailed. However, the section asking for follow up action to be taken had not been completed on any of the accident forms seen. Staff did not know if the manager carries out any analysis of accidents to see if there are patterns, trends or ways of avoiding future accidents. As previously mentioned in the environment section of this report, the water temperatures were found to be too hot. These had been checked three days before the visit took place and were satisfactory at that time. The home has a comprehensive range of policies and procedures in place. Staff said that their induction handbook refers them to the relevant policies and procedures. It is not clear how the manager makes sure staff are familiar with these. DS0000001500.V317169.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 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 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 2 3 X 3 3 X 2 X DS0000001500.V317169.R01.S.doc Version 5.2 Page 28 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 Regulation 15 Requirement The manager must make sure that each service user has a clear and detailed care plan, which identifies all their needs and how they will be met in a person centred way. The previous timescales of 30/09/06, 31/07/06, 15/02/06 and 30/08/05 have not been met in full. 2. YA12 YA14 16 The manager must make sure that service users are provided with activity and stimulation suitable to their wishes and needs. The manager must make sure that all staff are trained in current practice regarding moving and handling and that any equipment needed is provided. The manager must make sure that nutritional assessments are carried out for service users at risk from weight loss. A care plan must then be put in place to DS0000001500.V317169.R01.S.doc Timescale for action 31/01/07 31/01/07 3. YA18 13 31/01/07 4. YA19 12 31/12/06 Version 5.2 Page 29 make sure any action from the assessment is followed. 5. YA21 12 The manager must make sure that plans are in place for dealing with the ageing, illness and death of service users. The manager must make sure that staff are trained in the specialist needs of service users. For example, epilepsy and dementia. The organisation must review the staffing levels to make sure there are enough staff to provide a safe level of supervision and a good level of activity and stimulation for service users. The manager must make sure that staff’s records are available for inspection. The manager must make sure that accident reports are fully completed with details of the accident and any follow up or outcome to the accident. The previous timescale of 30/09/06 and 30/06/06 has not been met in full. 10. YA42 23 The organisation must make sure that temperature control valves on the taps are checked regularly to make sure the hot water is maintained at a safe temperature. 17/11/06 31/12/06 6. YA32 YA35 18 31/03/07 7. YA33 18 31/01/07 8. YA34 19 31/12/06 9. YA42 13 31/12/06 DS0000001500.V317169.R01.S.doc Version 5.2 Page 30 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 YA5 YA6 Good Practice Recommendations The organisation should make it clear who has signed contracts on behalf of service users. The manager should make sure that service users’ care plans and risk assessments show how they have been reviewed and who has been involved. The manager should also make sure that service users’ relatives are involved in this process. The organisation should review its homely remedies policy to make sure there is information on recording of homely remedies given. The manager should consider giving relatives or representatives of service users a copy of the complaints procedure. The manager should make sure that the contact details of the local adult protection unit are included in the protection of vulnerable adults policy. 3. 4. 5. YA20 YA22 YA23 DS0000001500.V317169.R01.S.doc Version 5.2 Page 31 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. 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