Inspection on 23/05/06 for St Philips Close

This inspection was carried out on 23rd May 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 17 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 14/11/06

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 23rd May 2006 9:30 St Philips Close DS0000001500.V295066.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 St Philips Close DS0000001500.V295066.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. St Philips Close DS0000001500.V295066.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 St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2005 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. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a poor home. This unannounced inspection was carried out by two inspectors between 9-30am and 5pm. The purpose of this inspection was to monitor progress in meeting the requirements and recommendations made at the last inspection, 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. However, the staff on duty had known the service users for many years and have a good knowledge of their needs and how they show their likes and dislikes. Information gained from a preinspection questionnaire and the home’s service history records were also used. Comment cards were left at the home to provide service users and visitors with the opportunity to comment on the service. There were no visitors to the home on the day of the inspection. Feedback was given to the Acting Senior Support Worker at the end of the inspection. Requirements and recommendations made during this visit, and outstanding from previous inspection visits can be found at the end of this report. What the service does well: The home has a high standard of decoration and furnishings. Each service users’ room is individual to them and shows their interests and preferences are catered for. Staff make sure that service users have regular and varied activities and write this in daily records. Staff are also good at encouraging family involvement. Staff said this was “getting better all the time and something we want to encourage.” St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 6 The home has a flexible approach to meeting service users’ needs. This makes sure that service users receive individualised care and can make choices about what they do. One service user when asked if he liked living at the home said Course I do. What has improved since the last inspection? What they could do better: All service users must be provided with a service users’ guide and preadmission assessments must be completed for all new service users. Care plans must be developed so that they are clear and give detailed information on service users’ needs and how these will be met. Care plans must also be reviewed to make sure the plan is still meeting the person’s needs. All identified risks must be assessed with an action plan put in place to show how risk is minimised. The home must address a number of staff training needs. These include, accredited medication training, NVQ’s (National Vocational Qualifications), care planning, risk assessment and training on the specialist needs of service users. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 7 Staff must follow proper hygiene procedures to prevent the spread of infection. The home must address health and safety issues, such as, making sure risk assessments are carried out for hazards identified around the home and proper completion of accident record reports. The manager must keep records of maintainence checks completed. Staff’s First Aid training must be up to date to safeguard service users and staff. Staff files must be available in the home for inspection purposes. This makes sure recruitment, training and supervision records can be seen. The home must have an effective quality assurance system, which seeks the views of service users and their representatives, to make sure there is continuous improvement in the service. Some consideration should be given to providing information in a format that is accessible to service users, examples being, the complaints procedure and service users’ contracts. Staffing levels and service users’ dependency levels should be reviewed to safeguard service users and staff and to make sure activities for service users are maintained. A number of requirements and recommendations have been made to address these issues. They can be found 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. St Philips Close DS0000001500.V295066.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 St Philips Close DS0000001500.V295066.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1.2,3 and 5 Service users do not have sufficient information available to make an informed choice about the home. EVIDENCE: The Statement of Purpose contains some pictures but is in very small print, making it difficult to read. There was no Service User Guide available. Contracts for service users were seen. These are still not in an accessible format and were not signed by service users or their representatives. The CSCI reports were available in the front entrance of the home. There was no evidence of pre-admission assessments having taken place and no policy in place to show how this will be done in the future. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 The care plans do not provide clear information on how assessed needs are to be met. Risk assessments are not carried out for identified needs or hazards. Staff are not properly trained in care planning or risk assessment. EVIDENCE: There was some excellent information in some service users care plans such as communication diaries, pen pictures and life histories. These were mainly written in the first person which is good practice. However, the format of the current assessments and care plans is difficult to follow. Some service users had assessments of their needs which had not been dated. Some had care plans written that did not seem to come from any assessed need. Plans were mainly focussed on physical, practical care needs and were not person centred. They didnt highlight service users hopes and dreams, likes and dislikes or future plans. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 11 Care plans for some service users had not been reviewed for over a year. One service user had no current assessment or care plans done since moving into the home. All information was from the previous placement. There were no formal reviews on file for any service user or any evidence of family involvement in this process. Daily notes were written for each service user, however, some messages regarding care needs were written in the homes communication book and not the service users personal file. Despite the gaps in documented care planning, the current staff were aware of the needs of service users and were seen to support them properly. Staff said they had not had any training in care planning. Risk assessments have still not been carried out for most of the service users. It was evident that risks do exist but they have not been assesed. Staff were aware of the need to assess risk, an example being for the use of cot sides. Staff had not had any training on risk assessment. Staff gave examples of how service users are involved in the day to day running of the home. Service users choose what to wear, choose the colours of the decoration in the home and what to eat. They also benefit from the more flexible approach introduced by the new manager and can choose when to get up and when to go to bed. Staff said that families were becoming more involved at the home and visiting more freqently. Staff said they encourage this contact and tell relatives and friends they can visit anytime. Staff also spend time with service users to try and find out their preferences. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected 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 Service users have varied and regular activity which meets their needs and preferences. Staff encourage and support service users to maintain relationships with their families and within the community. Service users are served a healthy, balanced diet. EVIDENCE: All service users had plans of activity. This ranged from acvtivity offered within the home , organised activity such as Gateway clubs and activity and leisure opportunities within the community such as shopping, theatre trips and swimming. Staff said they sometimes felt limited by the staffing numbers, there only being 2 staff on each shift during the day. The home does not have its own transport anymore. Buses and taxis are used. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 13 None of the current service users follow a religious faith. Staff were able to describe how they had planned to assist a service user who is Catholic to follow his faith if he had been admitted to the home. All service users have an annual holiday, suitable to their preferences and needs. Service users are assisted to maintain family contacts by telephoning them, visiting them and inviting them to the home. Staff encourage service users to make friends and spoke of one service user who had a friend who comes for tea. Staff gave examples of how they maintain service users’ independence and how they benefit from the flexible approach to routines. Staff said that one service user is now more alert through the day as he enjoys a lie-in some days. Staff were seen to support people with dignity and respect. The menus and choices available within the home have improved. Fresh produce is now readily available and service users likes and dislikes are catered for. A cooked breakfast is available every day if wanted, lunch is usually a snack type meal and the evening meal is the main cooked meal of the day. Beans on toast followed by fruit trifle was served at lunch time. The evening meal preparation was observed. This meal was home made burgers, chips and peas. Staff said they aim to provide the recommended 5 pieces of fruit and vegetables per day. Guidelines on food preparation and presentation were seen. Staff were aware of how to get a dietician for service users if they needed one. Service users are involved in menu choices through staffs observation of their likes and dislikes which are then written down. Service users were assisted with their meals with courtesy and respect. However, there was little social interaction between staff and service users throughout the meal. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 Personal and healthcare support is provided in a way that meets service users needs, despite the lack of care planning and training. Service users are not protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Staff supported people with personal care needs in private. They said they were aware of service users needs through their knowledge of them rather than what is written in the care plans. Staff said that new staff work alongside more experienced staff in order to get to know service users needs. Service users had details on file of health professionals they are involved with e.g. GP, District Nurse, Dentist, Chiropodist. Staff said that service users have an annual health and medication check. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 15 The home uses a monitored dosage, pre-packed system for the medicines. Senior staff are responsible for the administration of medicines. On the day of the inspection, the morning medication had not been signed for. There are no facilities for the storage of controlled drugs, should they be needed. The staff on duty could not locate the homely remedies policy and did not know if one existed. The medication cupboard had medication in stock that was not on the service users administration records. This medication should have been returned to the pharmacy. The homes returns book was empty. No record is kept in the house of medication that has been ordered so there is no way of knowing if there are any mistakes when medication is delivered. The list of staffs signatures for medication administration is out of date. The medication cupboard seemed warm for the storage of medications. There is a policy on medication, however this contained a list of abbreviations that should not be used. Staff had completed some training on medication. This training is not accredited training. Service users did not have any plans in place for their last wishes or funeral arrangements. Staff have not had any training relating to ageing, death and dying or the changing needs of service users. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 There are systems in place to make sure service users are protected from abuse. The complaints procedure does not enable service users or their representatives to have independence when making complaints. EVIDENCE: The complaints book was held in the front entrance of the home which meant any information in it would not be confidential. No complaints had been recorded. Staff were unaware of any complaints procedure and the process for dealing with them. There was no complaints booklet for service users although the statement of purpose made a brief reference to it. Staff said they had recently had training on the protection of vulnerable adults. They could describe different types of abuse and knew how to respond to allegations and suspicions of abuse. A recent adult protection issue has been properly addressed and investigated by the home. Procedures have been reviewed with regard to service users’ bank accounts and who can access money on their behalf. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 17 Financial records were well maintained. Service users’ monies were stored safely and proper handovers were taking place. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 Service users live in a homely, comfortable and clean environment. Some practices increase the risk of the spread of infection. EVIDENCE: The home is nicely decorated, well furnished and very homely. All service users have their own room which reflects their individual taste and interests. Bedrooms all had a sink but there was no liquid soap or paper towels for hand drying. The home is warm, clean and airy with a good layout. There is a hi-lo bath and hoist in the bathroom to assist service users. There were a number of infection control issues. Towels were on display in an open shelf unit in the bathrom. The clinical waste bin was not foot operated and incontinence pads were not being double bagged to prevent cross infection. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 19 Soiled linen is washed on the premises. Staff transfer soiled linen from a yellow bag into the washing machine. This practice increases the risk of infection. Staff were not aware of water soluble bags for washing of soiled linen. Staff said they had been trained on infection control. Staff were seen to assist service users at the toilet wearing gloves but not protective aprons. The laundry room was clean and tidy, however some washing tablets were found to be stored in an open shelf unit. Due to packaging, these could be mistaken for something edible and should be kept more securely. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 Staff appear to be competent and understand the needs of the service users despite the gaps in training. Staff are beginning to work well as a team and being given the support and supervision to do this Staffing levels need to be reviewed to ensure service users needs are met. EVIDENCE: Staff have not had any training specific to the needs of the service users. for example, dementia, pressure area care and changing needs due to ageing. However they seemed competent to meet the service users’ currrent needs. Staff said that communication and teamwork had been much better recently. One staff member said it was 100 better. More staff meetings are taking place and the manager has introduced a system for staff supervision. There was also a handover procedure that had recently been introduced. Only 20 of the staff team have achieved their NVQ level 2. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 21 Staffs files were not available for inspection as only the Home Manager has access to them. Recruitment records could not be checked. Staff on duty confirmed they had a CRB check done prior to employment. Staff said they felt there were gaps in their training, with some essential training being out of date. For example First Aid. There was a training matrix in place but this did not identify which staff had done the training. One staff member had not had any induction training despite having been in post for several months. Staff said they feel they meet the needs of the service users but the staffing levels affect their ability to get out with service users and dont reflect their increasing dependancy. There are currently 2 staff on each day shift and 1 on a waking night. Staff expressed concern that if there should ever be an emergency in the night, the on-call manager is too far away to respond to them for assistance and service users may have to go to hospital unaccompanied. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 22 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): 37,38,39,41 and 42 A manager has now been appointed on a permanent basis to provide leadership and direction to the home. Some of the homes practices with regard to policies, procedures and record keeping do not promote health and safety. EVIDENCE: The manager has now been appointed on a permanent basis and has requested a pack for registration as the registered manager. The home did not have a manager in place for over a year prior to this appointment. The manager is allocated 20 hours administration time to oversee this home and the one next door. The rest of the time she is on shift and not supernumary. Regulation 26 visits are carried out by the operations manager. These are not always done monthly or individually for this bungalow. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 23 The homes Statement of Purpose makes a brief reference to the companys Quality Assurance systems but does not state how this will be carried out. Staff were not aware of any quality assurance surveys having been done. Staff have access to a range of policies and procedures but did not seem to have a working knowledge of them. For example, handling complaints, medication, risk assessment. and accident reporting. Some of the homes’ record keeping is generally of a poor standard. Accident records were incomplete and had no follow up information on them. There was no analysis of them to see if there are any patterns and trends. Maintainence records were difficult to follow and there did not apear to be any records regarding the service history of equipment such as the hoist. There were no environmental risk assessments done for hazards within the home. COSHH records were well kept and up to date. Staff said they had training on moving and handling and fire safety. Staff said they felt listened to by their home manager but do not always feel supported by the organisation. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 24 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 1 2 1 3 1 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 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 3 3 2 2 2 2 2 2 2 2 x St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? 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 YA1 YA3 Regulation 5 Requirement The home must provide each service user with a Service Users Guide. Pre-admission assessments must be carried out to show how the home can meet assessed need. The previous timescale of 28/01/06 has not been met. 3. YA6 15 Each resident must have 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 15/02/06 and 30/08/05 have not been met. Staff must receive training in care planning. 4. YA9 13 All identified risk must be assessed with an action plan in place to minimise the risk. The previous timescales of 15/02/06 and 30/07/05 St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 26 Timescale for action 31/07/06 2. YA2 14 31/07/06 31/07/06 31/07/06 have not been met. Staff must receive training on risk assessment. 5. YA20 13 Staff must receive accredited training on the safe handling of medications. The previous timescale of 15/02/06 has not been met. 6. YA21 18 Staff must receive training specific to the changing needs of service users, with reference to their ageing and associated illness. The previous timescales of 15/02/06 and 30/08/05 have not been met. 7. YA22 22 Complaints records must be stored securely, maintaining confidentiality for complainants. Staff must be trained so that they understand and are familiar with the complaints procedure. 8. YA30 13 A risk assessment must be completed to show how any risk of cross infection is minimised when storing towels on an open shelf in the bathroom. The clinical waste bin must be foot operated. Incontinence pads must be double wrapped before being placed in the clinical waste bin. The practice of transferring soiled linen from yellow clinical waste bags into the washing machine must cease. The home St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 27 31/07/06 31/07/06 30/06/06 30/06/07 must use water-soluble bags that go straight into the machine. Aprons must be worn when assisting service users at the toilet or in the bathroom. Liquid soap and paper towels must be provided in each service users bedroom. 9. YA32 18 The organisation must make sure that 50 of the care staff achieve an NVQ. The manager must ensure that staff’s records are available for inspection. Staff must receive specialist training on the specific needs of service users e.g. dementia. Staff must receive training in relation to health and safety e.g. 1st Aid. 12. YA39 24 The home must have a quality 31/07/06 assurance system in place, which seeks feedback from service users and their representatives. Visits by the registered provider must take place on a monthly basis and individually for this registered home. The manager must ensure that staff have access to and understand all the homes policies and procedures. Accident reports must be fully completed with details of the accident and any follow up or outcome to the accident. Accident reports must be analysed to identify patterns and DS0000001500.V295066.R01.S.doc 31/12/06 10. YA34 19 30/06/06 11. YA35 18 31/07/06 13. YA39 26 30/06/06 14. YA40 12 31/07/06 15. YA41 YA42 13 30/06/06 St Philips Close Version 5.2 Page 28 trends. Records must show service histories of equipment used in the home and any maintainence work carried out. Identified hazards within the home must be supported by a risk assessment and action plan. 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 YA1 Good Practice Recommendations Some consideration should be given to provide service users with a statement of purpose and service user guide in a format that would be accessible to them. Some consideration should be given to provide residents contracts in format that they would be able to recognise. Staff should be provided with a medication procedure which is in line with the Royal Pharmaceutical Guidelines. The temperature of the medicine cupboard should be recorded to make sure medication is being stored at the correct temperature. 4. YA21 A plan of care with information on how the last wishes of service users would be met should be in place for all service users. Some consideration should be given to making the homes complaints procedure accessible to service users. Washing tablets should be stored more securely to ensure they are not mistaken for something edible. Staffing levels should be reviewed to make sure there are enough staff to ensure a good level of activity for service DS0000001500.V295066.R01.S.doc Version 5.2 Page 29 2. 3. YA5 YA20 5 6 7 YA22 YA30 YA32 YA38 St Philips Close users and a proper response to emergencies. This review should show how the manager provides management and leadership to both homes when included in the numbers of staff available. St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 St Philips Close DS0000001500.V295066.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!