Inspection on 21/02/07 for Stocks Hill

This inspection was carried out on 21st February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 7 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 20/07/06

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 21st February 2007 11:00 Stocks Hill DS0000001509.V328928.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.V328928.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.V328928.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 07747 487785 01977 668768 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.V328928.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 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 people supported use. The home has a car that can be used for the people supported and there is also a regular bus service into the City centre. The home provides care for five 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, petrol, toiletries and magazines. Stocks Hill DS0000001509.V328928.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 20 July 2006. To monitor the home’s progress in meeting the requirements of the key inspection a random visit took place on 6 December 2006. There have been no further visits until this unannounced key inspection, which was carried out by one inspector between 11am and 4-30pm. 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 are unable to say how they wish to be referred to. Staff at the home use the term people supported; 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 the people supported and staff. Information gained from a pre-inspection questionnaire and the home’s service history records were also used. Before the visit, comment cards were sent out to the people supported, relatives and visiting professionals to the home. Two of these have been returned and this information has also been used in the preparation of this report. There were no visitors to the home on the day of the visit. Feedback was given to the manager at the end of the visit. Thank you to everyone for the pre-inspection information, returned comment cards and for the hospitality and assistance on the day of the visit. Requirements and recommendations made during this visit can be found at the end of the report. Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Although there is still some work to do, the care plans, health support plans and risk assessments of the people supported have improved in the level of detail that is in them. Also, some have been signed by a relative to show they are in agreement with them. The kitchen has been cleaned more thoroughly and some new appliances have been purchased. The dining room has been decorated. Improvements have been made to the systems for medication administration. The complaints procedure now ensures confidentiality for anyone wishing to complain. The arrangements for the safekeeping of monies of the people supported now give them greater protection. Staff are working more effectively as a team. The manager has now completed the Registered Managers Award. Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stocks Hill DS0000001509.V328928.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.V328928.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. The people supported or their representatives have sufficient information available to make sure they can make a choice about the home. The people supported have a pre admission assessment carried out to make sure the home can meet their needs. However, this has not been kept under review. The people supported have updated contracts but are not fully aware of the additional charges made by the home. 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. Some of the information in the Statement of Purpose needs to be updated with regard to the CSCI. (Commission for Social Care Inspection). Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 10 The people supported now have an up to date contract with the organisation, which gives details of the current costs for a place at the home. However, the contracts do not have all costs listed in them. The people supported contribute to petrol for the home’s vehicle. There is still no evidence of any agreement having been made to this arrangement. It is not listed in the contracts. However, the organisation’s operations manager has spoken with the inspector about this matter and is currently contacting the families of the people supported, in order to show that they are in agreement with this charge. A relative who returned a survey said, “Information could be better.” The needs of the people supported have been assessed before they moved into the home to make sure the home could meet their needs. However, this was some time ago and re-assessment has not taken place, even though the needs of the people supported have changed. This means that the current care plans and risk assessments have not been developed from a full assessment and this could lead to important care needs being overlooked. The manager said that all of the people supported were going to be having person centred planning meetings in the near future, which should highlight their current needs. She also said she would develop an assessment tool for use in the meantime and she did some work on this during the visit. Stocks Hill DS0000001509.V328928.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, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Despite the gaps in documented care planning and risk assessment, the needs of the people supported are met and they are supported properly. The people supported are involved in the day-to-day running of the home and can influence what happens there. EVIDENCE: Some progress and improvements have been made with the standard of care plans and risk assessments. All the old information is now archived in the bedrooms of the people supported. Many of the care plans are detailed and specific, giving good instruction to staff on how and when to provide care and support. Nutritional assessments have now been carried out for a person at risk from weight loss and a care plan is in place regarding the risk of pressure Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 12 sores. The plans are also evaluated and reviewed regularly. Staff said they find them useful, especially for checking care needs if they are not sure. One staff member said that even though they had worked at the home some time they still read the care plans regularly to refresh themselves on the care needs of the people supported. This is good practice. Care plans are reviewed through team meetings and meetings with the person supported and their keyworker. Notes of these meetings are kept. Staff are able to talk confidently about the care and support they provide. This matched up with what was written in the care plans. They have good knowledge of the needs of the people supported. In a returned survey, a relative commented that they didn’t feel the needs of the people supported are always fully met and feels this is down to unrest at the home. As mentioned in the previous section of the report, assessment of the needs of the people supported has not been done for some time and this could lead to care needs being missed. For example, one of the people supported has no care plans for assistance needed at the toilet or whether support is needed with some personal hygiene such as teeth cleaning. Also the focus of the plans still seems to be on practical care tasks and behaviour management. There is not a lot of information on the likes and dislikes of the people supported, how they communicate their needs if they have no verbal communication or their future hopes and dreams. The manager said that this information will be in the person centred plan of each of the people supported. In a returned survey a relative said, “Some staff don’t always pick up on non-verbal communication.” As part of the care planning process, staff keep a daily journal for the people supported. In the main, these are used properly with a good standard of report being entered in them. However some entries made were negative and forceful sounding about the person supported. The manager is aware of these entries and is currently dealing with the matter. All of the risk assessments seen are now reviewed and up to date. A relative has also signed a risk assessment for the use of a baby alarm to monitor the epilepsy of one of the people supported. This is good practice. Staff gave examples of how the people supported are involved in the day-today running of the home. The people supported have meetings, which are held on a monthly basis. Due to the complex needs of the people supported, meetings cannot be held in the traditional way of everyone sitting down together. Staff make efforts to be flexible with the meetings in order to try and include everyone. The reactions of the people supported are noted in the minutes and staff try and interpret this as best they can. Staff said the people supported make choices on a daily basis about what to eat, what to wear, when to get up or go to bed and what activities they do. Staff said it is important to respect a person’s choice to do nothing at times and to just spend time relaxing. Staff also said that the people supported who have no verbal Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 13 communication can let you know if they are not happy by facial expressions or actions. Stocks Hill DS0000001509.V328928.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 good. This judgement has been made using available evidence including a visit to this service. The people supported benefit from varied and regular activity, which suits their needs and preferences. Staff encourage and support the people supported to maintain relationships with their families, friends and within the community. The people supported benefit from a varied, healthy and balanced diet. EVIDENCE: The people supported are involved in various activities each week. This ranges from day centres, an activity and leisure service, going to the pub, shopping and meals out. The people supported are encouraged to meet up with old Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 15 friends and to keep in contact with their families. One of the people supported has been assisted by staff to get back in contact with a relative they had lost touch with. The person supported repeated the name of this relative and smiled each time they were mentioned. Staff have made good efforts to make sure this contact is maintained. Another of the people supported sees his family every week. Staff take him to these visits. Staff said that the people supported are known in the local community and use all local facilities such as shops and pubs. One person attends a local church and has a support plan in place to make sure this happens. During the visit, some of the people supported were out at day centres. Another person went out to the pub for a lunchtime pint and another was going to his mother’s house for tea. Some information on leisure and likes and dislikes is not well documented in the plans of the people supported. Staff tend to rely on word of mouth for passing on information on interests and contacts. One of the people supported has a friend he meets up with now and then. There is no mention of this in the care plan. One of the downstairs rooms at the home is now a sensory room, where the people supported can have a “chill out”, listening to music and experiencing the variety of sensory equipment that has been bought. Staff were seen to support people with courtesy and thought for their dignity. They knocked on doors of bedrooms and bathrooms and waited to be asked in. Staff spoke about the importance of making sure the people supported are as independent as possible. They said they are encouraged to get involved in household tasks and to make drinks and snacks for themselves. One staff said, “Being independent means your life is better.” There is lots of social interaction between the staff and people supported. Staff always explained what they were doing and what was happening throughout the day. Menus are pre-planned at the home. However, if a service user wants something different to what is on the menu, this can be done. A good variety of food is available and staff try to make sure there is a good selection of fresh produce available. The lunchtime meal on the day of the visit was steak pie, chips and mushy peas. The people supported had chosen to have their main meal of the day at lunchtime. Staff said that the main meal is usually at teatime but can be varied according to people’s preferences. Drinks and snacks such as fruit are readily available throughout the day. The people supported were assisted with their meals as necessary. Staff sit down at the mealtime and it is made into a social occasion. Protective clothing and any adapted plates or cutlery are available for the people supported. This ensures their dignity and independence when eating. Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 16 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people supported are assisted properly with their personal care needs. Health care support is provided in a way that meets the needs of the people supported. The people supported are, in the main, protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Staff assist the people supported with their personal care needs in private and with dignity. The people supported are encouraged to be as independent as possible. For example, care plans show how staff give support in the bathroom to a person supported who has epilepsy and needs full supervision. The plans show how this person’s privacy and dignity are maintained. Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 17 The care plans also have details of any health professionals that the people supported see. These include, GP, consultants, specialist nurse, psychologist and chiropodist. Records are kept of any health appointments and their outcome. Each person supported has a communication book for each health professional they see. This is good practice. Staff always accompany the people supported on their appointments. Some of the people supported did not seem to have a dentist. The home manager said she will look into this and make sure a referral is made. The home works closely with psychiatrists and community nurses to develop behaviour support plans for the people supported. Staff are trained in intensive interaction techniques. They said this is a way of communicating with service users to minimise behaviour that challenges others. The home uses a monitored dosage pre-packed system for medicines. All staff take responsibility for the administration of medication and are trained to do so. There are good ordering and checking systems in place, with a clear audit trail for any unused medication returned to the pharmacy. The medication administration record (MAR) sheets were checked and showed no errors in administration. However, there were some handwritten entries on the MAR sheets that had not been checked and countersigned as correct. This could lead to errors in medication administration. This was also brought up at the last key inspection in July 2006. The home has a controlled drug, which is kept on the premises and administered by a community nurse. The manager has put good systems in place to show this is managed well. Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 18 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. The people supported or their representative’s concerns are listened to and acted upon. The people supported 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 and pictorial format to make it more accessible to all. Some of the information regarding the CSCI needs to be updated. Any complaints the home has received have been dealt with properly. The manager is currently dealing with a complaint and showed evidence that this was being handled properly. Staff have received training on the protection of vulnerable adults. They are able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They are also able to describe the different types of abuse. One staff member said, “It doesn’t matter what sort of abuse it is, any abuse needs reporting.” Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 19 Good records are kept of the finances of the people supported and their monies are kept safe. Handovers of the monies now take place at each shift change and staff sign to say the monies are correct. The manager checks the records on a weekly basis and also archives and checks all the receipts on a monthly basis. This is good practice. Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 20 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 homely, mainly clean and safe and hygienic. Staff’s practices control the spread of infection. EVIDENCE: The home is warm, homely and comfortable. All of the people supported have their own rooms, which are decorated and furnished to a high standard. The rooms reflect the interests and personality of the people supported. The dining room has recently been redecorated and staff said they are still in the process of getting new curtains, pictures and ornaments for this room. The carpet in the dining room has a damp, stale smell and must be deep cleaned or replaced. The hall carpets had a similar odour. Through discussion Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 21 with staff it was felt that the odour might be coming from under the carpet in that it wasn’t drying out properly after being shampooed. The home manager said she will look into replacement or further cleaning. The lounge is comfortable and well furnished. However, the carpet in here is worn in the doorway and around the seam. This could eventually come undone and create a trip hazard. This must be made safe. There are some new appliances in the kitchen; cooker and fridge. The standard of cleaning in the kitchen is improved. Cupboard doors and work surfaces are clean. The manager said she has put a request in for a complete refurbishment of the kitchen and is hoping this will soon be done. The toilet on the ground floor has been decorated and cleaned more thoroughly. The bathroom is equipped with assisted bathing facilities. It is pleasing to see that the bathroom is decorated attractively with pictures, painted tiles and plants. It makes the bathroom an interesting and relaxing place to be. Clinical waste is properly managed. Staff can describe the measures in place to prevent the spread of infection. Protective clothing is worn when attending to the personal care of the people supported. There is liquid soap and paper towels available at every sink to make sure of good hand hygiene. Staff are trained in infection control. Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are competent to meet the needs of the people supported; they are well supported and supervised. The people supported are protected by the home’s recruitment procedures. EVIDENCE: There are staff on duty throughout the day and night. There are usually two or three staff on the morning shift and three staff on the afternoon shift. At night there is one member of staff with another staff sleeping in who can be called upon in emergency. The manager works alongside staff on shift and also has some time to complete her management role. Staff said they feel there are enough staff on duty to meet the needs of the people supported. They said they never feel too rushed and there is plenty of opportunity to spend time with the people supported. Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 23 Recruitment is properly managed by the home; interviews are held, references and CRB (Criminal Record Bureau) checks are obtained before staff start work and checks are made to make sure staff are eligible for work. Staff’s training was mostly up to date. Good records are kept of staff’s training and when their updates are due. The manager assesses this every month to make sure training doesn’t get missed. Staff spoke highly of their training and the support they get from the manager. One staff member said it wasn’t just courses that were important in their role but the training they get at the home by working alongside experienced people was, “Invaluable”. Staff have received training on the specialist needs of the people supported such as epilepsy and behavioural issues. 75 of the staff team have achieved an NVQ (National Vocational Qualification) in level 2 or above. More staff are also currently working on their NVQ. One staff member said they had enjoyed doing the NVQ and that it had made them think more when doing their job. All staff spoken to said they felt they now had a settled team and are working effectively with good communication between themselves. The manager also said that teamwork had improved and the teambuilding work seems to be paying off. The manager is aware of the signs of any problems with teamwork and said she tries to diffuse situations before they become major issues. In a returned survey a relative said, “There is a lot of tension, staff unsettled, the last few times I have visited, I have not felt comfortable.” Staff receive supervision on a regular basis and all have an annual appraisal of their performance. One staff member said supervision was, “Regular as clockwork”. They also said they found it useful to reflect on how they were performing and what they could do to improve. Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 24 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 and42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, the interests of the people supported are seen as important to the manager and staff and are safeguarded at all times. EVIDENCE: The home has an experienced manager who is a Registered Nurse and has completed her Registered Managers Award. She works alongside staff to make sure of good practice. She also has some administration time to complete her management tasks. Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 25 The operations manager visits the home on a monthly basis to carry out regulation 26 visits. This involves interacting with and talking to the people supported and staff about the home. A report of these visits is made showing details of any action to be taken to improve the service. In addition to this, the organisation carries out a quarterly service review, as part of its quality assurance programme and is planning to include comments from relatives in this in future. Staff carry out weekly or monthly health and safety checks around the home such as fire alarms, emergency lighting, water temperatures and checks on the house vehicle. Maintenance records are well kept. Environmental risk assessments are completed and up to date. Accident or incident reports are completed. However, there is no section for follow up action to be taken after any accident or incident. Due to the small number of accidents, the manager does not carry out any analysis of accidents to see if there are patterns, trends or ways of avoiding future accidents. She said she would do this if there were any increase in them. She said she is aware of the accidents due to completing her monthly report on the home. Information is collated and analysed on behavioural incidents. The home’s electrical wiring certificate is now over six months out of date. The manager said the housing association who own the property are responsible for this but that she will remind them it needs to be done. The home has a comprehensive range of policies and procedures in place. Staff are given a list of these when they first start work, along with information on where to find them. The organisation has just started to give all staff their own health and safety handbook which links with the training they provide. Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 26 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 2 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 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 3 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 X 3 X 3 X X 2 X Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 27 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 YA5 Regulation 5 Requirement The organisation must provide each person supported with a contract, which gives details of any additional charges made, including the contribution to petrol for the house vehicle. The previous timescales of 01/09/06 and 31/01/07 have not been met in full. The manager must make sure that each person supported has a clear and detailed care plan, which is generated from an assessment and identifies all the needs of the people supported and how they will be met in a person centred way. The previous timescales of 30/11/06 and 28/02/07 have not been met in full. The manager must make sure that all risks are fully assessed and there is an action plan in place to minimise the risk. The previous timescales of 30/09/06 and 28/02/07 have not been met in full. Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 28 Timescale for action 30/05/07 2. YA6 15 30/05/07 3. YA9 13 30/05/07 4. YA20 13 5. 6. 7. YA24 YA30 YA42 13 16 23 The manager must make sure that handwritten entries on the medication administration records are signed, checked and countersigned as correct. The manager must arrange for the repair or replacement of the lounge carpet. The manager must arrange for deep cleaning or replacement of the dining room and hall carpets. The manager must make sure that the overdue electrical wiring safety test is completed. 30/03/07 30/06/07 30/06/07 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA42 Good Practice Recommendations Accident records should be completed with details of any follow up or outcome to the accident. Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Stocks Hill DS0000001509.V328928.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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