Inspection on 20/07/06 for Stocks Hill

This inspection was carried out on 20th July 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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stocks Hill 30/01/09

Stocks Hill 21/02/07

Stocks Hill 01/02/06

Stocks Hill 05/09/05

Stocks Hill 07/03/05

Stocks Hill 10/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Stocks Hill 2 Stocks Hill Methley Leeds West Yorkshire LS26 9JD Lead Inspector Dawn Navesey Key Unannounced Inspection 20th July 2006 09:40 Stocks Hill DS0000001509.V303774.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 Stocks Hill DS0000001509.V303774.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. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stocks Hill Address 2 Stocks Hill Methley Leeds West Yorkshire LS26 9JD 01977 668768 01977 553651 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) TACT UK Ltd Mrs Nikky Suzann Smith Care Home 6 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: The home is located in the village of Methley between Leeds and Wakefield. It is within easy walking distance of the local shops, and post office. There are a number of pubs in the village which the service users use. The home has a car that can be used for service users and there is also a regular bus service into the City centre. The home provides care for six people who have a learning disability. Nursing care is not offered at the home but if it should become necessary the local healthcare team will provide it. Stocks Hill is a detached property situated in a quiet street and provides domestic style accommodation. Bedrooms are on two floors and all are single. There is no lift at the home. There is a safe enclosed garden to the rear of the property with a patio, barbeque and greenhouse. The current scale of charges at the home is £1310.25 - £1381.40 per week. Additional charges are made for chiropody, hairdressers, toiletries and magazines. Stocks Hill DS0000001509.V303774.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 This unannounced inspection was carried out by one inspector between 940am and 4-15pm. 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 with service users and staff. Most of the service users have complex needs and discussion with them was limited as they do not all have verbal communication. Information gained from a preinspection questionnaire and the home’s service history records were also used. Comment cards were sent out to a relative prior to the inspection and a number were left at the home to provide service users and visitors with the opportunity to comment on the service. None of these have been returned as yet. There were no visitors to the home on the day of the visit. Feedback was given to the Senior Support Worker at the end of the inspection. Requirements and recommendations made during this visit can be found at the end of the report. Stocks Hill DS0000001509.V303774.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: All service users must be provided with an up to date contract showing details of their fees and any other charges. Each service user must have a clear and detailed care plan, which through assessment identifies all their needs, including health needs, and how they will be met in a person centred way. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 7 All identified risks must have an action plan in place to show how risk is minimised. The home must address a number of issues regarding medication. The medication file, which holds the medication administration record sheets must be kept clean. It was very dirty and sticky and some pages were almost stuck together. Handwritten entries on the medication administration record sheets must be signed, checked and countersigned to make sure they are correct. The medication keys must be kept in the personal possession of the member of staff in charge of the home at all times. The complaints book was held in the home’s office in the hall, all staff have access to this book. Confidential information regarding a complaint was documented in here. Confidential matters held in the complaints book must be maintained as such to give people independence when making a complaint. Service users’ monies and bank - books must be protected from potential abuse and stored more securely. The procedure of service users contributing to petrol for the house vehicle must be reviewed to make sure this is fair to all. Staff files must be available in the home for inspection purposes. This makes sure that recruitment; training and supervision records can be seen. The manager must support the staff to work effectively as a team to make sure all service users’ needs are met. Some consideration should be given to including comments from relatives and visitors to the home in the quality assurance procedure. Accident records should be completed with details of any follow up or outcome to the accident. Accident reports should be analysed to identify any patterns and trends. 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. Stocks Hill DS0000001509.V303774.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 Stocks Hill DS0000001509.V303774.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): 1,2,3,4 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 have sufficient information available to make an informed choice about the home. Any future service users can be sure their needs will be assessed prior to moving into the home. Service users do not have an up to date written contract so are not aware of the cost of their placement and any additional charges. EVIDENCE: There is an up to date Statement of Purpose presented in a brochure format giving information about the home and the service they provide. Each service user has their own copy of the Service User Guide. This guide has been produced using pictures, symbols and easy words to make the information more easily understood. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 10 All current service users have been assessed prior to their admission to the home. There have been no new admissions to the home since 2003 but the home has an admissions policy. Staff said that prior to any admission, service users are assessed and invited to come to the home for visits, overnight stays and meals. The time taken to do this varies according to each person’s needs. All of the service users have an individual contract in a picture and easy word format. However, the contracts had not been reviewed since 2003 and did not have the current fee levels noted on them. Also service users are now contributing to petrol for the home’s vehicle. There was no evidence of any agreement having been made to this arrangement. Stocks Hill DS0000001509.V303774.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Despite some gaps in documented care planning and risk assessment, service users needs are met and they are supported properly. Service users are involved in the day-to-day running of the home and can influence what happens there. EVIDENCE: All of the service users have care plans that clearly identify some of their needs. The care plans however, do not seem to have been developed from any current assessment of their individual needs and do not seem to cover every aspect of their lives. Staff said, that the home manager completes the care plans after asking staff and service users’ relatives for their contribution. There is no written evidence of this. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 12 The information in the care plans available is detailed and very specific as to how some tasks need to be done in order that service users’ needs are met. Plans were mainly focussed on physical, practical care needs but were not person centred. They did not highlight service users’ aspirations and dreams, likes and dislikes and how a service user communicates this to others. Some service users did not have moving and handling plans even though it was clear they had needs in this area. Nutritional assessments had not been carried out for service users who were at risk from weight loss or gain. Staff were, however, aware of the care needs of service users and could talk about the detail of how service users like to be supported in their daily routines. The care plan information available was up to date. Key workers hold monthly meetings with service users to see where any changes need to be made. There were no reviews, which included relatives or other professionals, for any of the service users’ plans looked at. Some information was kept in service users’ files in the office and some was kept in their own rooms. This could lead to confusion over what was current information. Some of the old information needs to be archived. Risk assessments have been completed for service users as part of the care planning process. Some of the risk assessments have identified what the risk is but do not have an action plan to show how risk will be minimised or what to do in the event of an emergency arising, for example, choking or a fall. One service user has a baby monitor in his room so that he can be heard if he has an epileptic fit. The monitor receiver is kept in the lounge and therefore everyone in the home can hear activity and any conversation in his room. Staff were not aware of any agreement in place on the use of this monitor. The service users were assisted in making choices about what to eat and how to spend their time. Service user meetings take place on a regular basis and show how service users are involved in decision-making. One of the service users said, “I like living here”. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected 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 this service. Service users have varied and regular activity appropriate to their needs and preferences. Staff encourage and support service users to maintain relationships with their families and friends. Service users are served a healthy, balanced diet. EVIDENCE: All service users had plans of activity. This ranged from activity offered within the home, organised activity such as day centres and an opportunities service and leisure activities in the community such as bowling, cinema, parks and trips out to the coast. Staff rotas are worked out with flexibility to make sure Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 14 regular and varied activity takes place. One service user said he enjoyed baking in the home. Staff talked about their current gardening project where staff and service users are working together to improve the garden surroundings. Service users have been involved in preparing pots and making pictures and plaques for the garden. Holidays have recently taken place. One service user had just returned from a holiday in Blackpool and although he could not verbally say how much he had enjoyed this, he was smiling and laughing when it was spoken about. Some service users are regular visitors at their family’s homes. Staff support them to do this and accompany them if needed. Family members are also invited to the home and can go along on trips out or get involved in activity at the home such as parties and barbecues. Service users are encouraged to maintain their family contacts and to keep in touch with service users who have moved on from the service. Service users use the local shops, pubs and churches in their village. One service user is supported to use the Catholic Church and to receive communion when he wants to. There is a detailed plan in place for how this is achieved and how staff must support him. Staff were seen to support people with courtesy and thought for their dignity. One staff member said it was important to allow service users to be as independent as possible for their pride and dignity. Service users are encouraged to take part in daily household activity such as cleaning, shopping and taking their laundry to be washed. Menus are not pre-planned at the home. Meals are prepared by asking service users what they want on the day from what food is available in the home. A good variety of foods are bought on the weekly shopping trip and staff try to make sure there is a good selection of fresh produce available. The food prepared is documented on a menu chart and staff check with this to make sure there is variety for service users. Staff offered choices of food to service users by showing them the actual foods. On the day of the visit the lunch- time meal was sausage rolls with spaghetti or salad followed by fresh fruit. The main meal of the day is served in the evening. Drinks and snacks were readily available throughout the day. Service users were offered extra fluids, as it was a very hot day. Staff said they are aware of service users’ likes and dislikes through word of mouth between staff and their observation of service users. It would be good practice to have service users likes and dislikes written down to make sure all staff are aware of them. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. 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. Personal and healthcare support is provided in a way that meets service users’ needs despite a lack of health action planning. Service users are not protected by the homes practices for dealing with medication. EVIDENCE: Staff supported service users with their personal care needs in private. Service users are encouraged to take as much part in this as they can. Staff were seen to allow people to choose what to wear and when to have a bath. Service users are involved with a variety of health professionals such as GP, dentist, chiropodist, dietician and psychologist, depending on their needs. Each service user has a contact book for each professional they are seeing so that details of any appointments can be written down and communicated to Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 16 staff. Some service users’ books did not have the contact details of the health professional listed in the book or anywhere else on their personal files. Service users did not have health action plans showing how preventative action is taken to try and make sure people stay healthy. An example of this being that a bowel chart was being used to monitor bowel movements yet there was no action plan in place to say why this was needed. One resident is on a weight loss diet. This diet has been taken from the Internet and does not seem to have been approved by a dietician or doctor. However, the diet plan offered healthy choices. The home uses a monitored dosage pre-packed system for medicines. All staff take responsibility for the administration of medication. Staff said they had been trained to do this. The medication file, which holds the administration record sheets and guidelines on medications, was very dirty and sticky. Some pages were almost stuck together. Handwritten entries on the medication administration record sheets had been made for medications prescribed outside of the pre-packed system’s cycle. They had not been signed, checked or countersigned to make sure they were correct. This practice has the potential to put service users at risk. The medication keys must be kept in the personal possession of the member of staff in charge of the home at all times. Staff have a good awareness of the changing needs of service users as they get older and said they would ask for training as people’s needs change. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected 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 poor. This judgement has been made using available evidence including a visit to this service. There are some systems in place to make sure service users are protected from abuse. Procedures to protect service users from financial abuse are not robust enough. The complaints procedure does not enable autonomy or confidentiality when complaints are made. EVIDENCE: The home has a complaints procedure in place. Service users are given one in a format that is more easily understood as it is in picture and easy word format. Staff were able to describe the complaints procedure and what to do in the event that they received a complaint. The complaints book was held in the home’s office, all staff have access to this book. Confidential information regarding a complaint was documented in here. Any confidential information regarding complaints must be kept as such, to give people independence when making a complaint. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 18 Staff said they had received training on the protection of vulnerable adults. Since the last inspection there have been four adult protection issues, which have been dealt with properly. Staff were able to describe the different types of abuse and what they would do if they suspected abuse or had allegations of abuse made to them. Service users’ personal money and bank- books are not kept securely. All staff and other service users could have access to their money tins. The member of staff in charge agreed to remedy this at the time of the visit and put them in a more secure place. Handovers do not take place at each shift change and staff do not sign to take responsibility for the safekeeping of service users’ money. The home manager does not have a system in place for checking service users’ financial transactions. All of this practice increases the risk of financial abuse. Service users are expected to make a contribution to the petrol for the home’s vehicle. This contribution varies according to what money each service user has, as opposed to how much use they have of the vehicle. This must be reviewed to make sure there is no abuse of service users’ money taking place. Service users property lists were not up to date. No purchases had been entered on the lists since 2003. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable and safe environment. Sufficient specialist equipment is provided to enable service users to maximise their independence. Some practices at the home increase the risk of the spread of infection. EVIDENCE: The home is well furnished, comfortable and homely. All service users have their own room, which reflects their individual taste and interests. A spare bedroom is currently being used as a relaxation room with soft furnishings and sensory equipment in place. Staff said that some service users were really enjoying time spent in this space. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 20 The bathroom is equipped with assisted bathing facilities. There are ample toilets for service users. Clinical waste is properly managed and staff wear protective clothing when attending to service users’ personal care needs. The laundry room was clean and tidy. However there is a freezer in this room with additional food supplies in. This freezer must be moved as this practice increases the risk of cross infection. The kitchen is in need of decoration and some cleaning. Many of the cupboard doors were sticky with foodstuffs that had not been cleaned off, as were some of the work surfaces. The washing up bowl was heavily stained with ground in marks. This needs replacing. Staff said that the kitchen is the next room in the house to be decorated on the maintenance schedule. The tiles and the paintwork in the ground floor hall toilet were also in need of cleaning. The home is now using a “walkie-talkie” system so that staff and residents can summon immediate assistance when required. Staff said they had found this effective and useful. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. 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. Staff are properly supervised but not working effectively as a team. EVIDENCE: Staff said they have completed essential training such as first aid, food hygiene, infection control, moving and handling, dealing with aggression and protection of vulnerable adults. In addition to this, staff said they had received training on medication, healthy eating, health and safety and positive interaction. The person in charge on the day of the visit was a senior support worker who confirmed that all staff have had interviews, had references taken up and a CRB (Criminal Records Bureau) check done. Staff’s training and recruitment records were not available on the day of the visit as only the manager and deputy manager have access to them and they were not on duty. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 22 50 of the staff team have an NVQ (National Vocational Qualification) level 2 in care. The rota is flexible in order to meet the needs of service users. Staff said they feel there are always enough staff on duty to make sure service users’ needs are met and that they can get out on activities. Staff said they receive regular supervision and find this useful. Staff meetings take place on a monthly basis with the minutes being available for those staff that can’t attend. Staff expressed some concern about teamwork within the home and poor staff morale. Some staff are not getting on with others. This is affecting practice in that proper handovers are not taking place, as some staff will not speak to each other. This is also having a detrimental effect on the atmosphere in the home. Some teambuilding events have taken place and staff said the home manager and operations manager are trying to resolve issues between staff. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39 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 in the main, well managed with the interests of service users seen as important. Some of the home’s practices with regard to record keeping do not promote health and safety. EVIDENCE: The registered manager is back from maternity leave. Staff said they feel she is working hard to address some of the teamwork issues within the home. Some staff said they were confident that she listens to them and supports them, others did not feel as supported. Service users are consulted through meetings and the operations manager’s quarterly quality assurance visit. Staff said that service users’ relatives are consulted in an informal way when they visit. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 24 They operations manager also carries out a regulation 26 visit every month and speaks with service users and staff. Record keeping within the home is of a variable standard. Maintenance records, COSHH (Control of Substances Hazardous to Health) and environmental risk assessments were well kept. Health and safety checks including fire are done regularly and documented properly. Staff were unable to locate some of the records such as the electrical wiring safety certificate. Accident reports were incomplete and had no follow up information on them. Service users financial transactions were not checked as correct and there were some gaps in the care planning records. Staff said they had received training in health and safety. All relevant policies and procedures are in place. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 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 3 3 2 3 X X 2 X Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 26 NO 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 YA5 Regulation 5 Requirement The home must provide each service user with an up to date contract, detailing current charges and any additional charges. Each service user must have a clear and detailed care plan, which identifies all their needs and how they will be met in a person centred way. All identified risks must have an action plan in place to minimise the risk. The medication administration records must be kept in a good condition so that records can be easily accessed and read. Handwritten entries on the medication administration records must be signed, checked and countersigned as correct. The medication keys must be kept in the personal possession of the member of staff in charge of the home at all times. Complaints records must be stored securely, maintaining confidentiality for complainants. DS0000001509.V303774.R01.S.doc Timescale for action 01/09/06 2 YA6 15 30/11/06 3 4 YA9 YA20 13 13 30/09/06 01/09/06 5 YA22 22 01/09/06 Stocks Hill Version 5.2 Page 27 6 YA23 23 The home manager must ensure that service users’ monies and bank- books are stored securely and that there are systems of accountability in place to protect service users. The organisation must review the policy of service users contributing to petrol for the house vehicle to ensure it is fair to all. The manager must ensure that staff’s records are available for inspection. The manager must support the staff to work effectively as a team to make sure all service users’ needs are met. The registered person must produce an improvement plan setting out the methods by which, and the timetable to which the registered person intends to improve the services provided in the care home. 01/09/06 7 YA23 5 01/09/06 8 9 YA34 YA33 19 18 01/09/06 30/09/06 10 *RQN 24a 07/09/06 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 YA22 YA42 Good Practice Recommendations Some consideration should be given to including comments from relatives and visitors to the home in the quality assurance procedure. Accident records should be completed with details of any follow up or outcome to the accident. Accident reports should be analysed to identify any patterns and trends. Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 28 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 Stocks Hill DS0000001509.V303774.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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