Inspection on 12/08/08 for Stocksbridge Neuro-Rehabilitation Centre

This inspection was carried out on 12th August 2008.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stocksbridge... 31/07/07

Stocksbridge... 02/08/06

Stocksbridge... 02/02/06

Stocksbridge... 08/07/05

Stocksbridge... 11/01/05

Stocksbridge... 29/06/04

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Stocksbridge Neuro-Rehabilitation Centre 2a Haywood Lane Stocksbridge Sheffield South Yorkshire S36 2QE Lead Inspector Shirley Samuels Key Unannounced Inspection 12th August 2008 09:45 Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.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 Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.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. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stocksbridge Neuro-Rehabilitation Centre Address 2a Haywood Lane Stocksbridge Sheffield South Yorkshire S36 2QE 0114 2837200 0114 2887736 stocksbridge@schealthcare.co.uk www.schealthcare.co.uk Active Care Partnerships Ltd 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) Kathryn Sandra Oakley Care Home 24 Category(ies) of Physical disability (24) registration, with number of places Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home is for service users who require neurological care. The minimum numbers of staff on duty must comply with the staffing notice dated 6/3/00 and attached (referring to previous name of home; Holly Lodge). One specific service user of the age of 17 years and named on variation dated 5th October 2006, with Physical Disabilities / Neurological needs may reside at the home. One specific service user over the age of 65 years and named on variation (V27411) dated 18th December 2006, with Physical Disabilities/Neurological needs may reside at the home. 31st July 2007 Date of last inspection Brief Description of the Service: Stocksbridge Neuro-Rehabilitation Centre is a purpose built service offering respite, assessment and rehabilitation to adults aged 18 - 65 years who have an acquired brain injury or neurological condition. The building has therapy rooms, independent living skills kitchens, lounges for relaxation and access to paved and lawned gardens. The centre overlooks the village of Stocksbridge. It is near the bus routes and the local shops. It is also within easy reach of Sheffield city centre and the motorway network. The building has two levels, with a passenger lift providing access to both. Rooms and corridors are designed to accommodate wheelchairs. The staffing structure consists of an interdisciplinary team of professionals made up of a consultant clinical neurophysiologist, care manager, service manager, nurses, behavioural technicians, two physiotherapist, two occupational therapist, speech and language therapist and rehabilitation support workers. The ancillary workers such as the cooks, the domestics and the maintenance persons are also employed to support the service. The basic weekly fee is £2,384.00. This includes, nursing care, therapy input as assessed on admission and on reviews, board, lodging, laundry, house keeping, meals, support when attending out patient appointments and a programme of social and recreational activities to complement therapeutic activities. The fee does not include the cost of hairdressing, chiropody, toiletries, maintenance of private equipment, private telephone, internet access, replacement clothing, Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 5 footwear and underwear. Stocksbridge Neuro-Rehabilitation Centre is a part of Active Care Partnerships. At the reception area in the main entrance information is made available about the parent company for visitors and relatives. There is also a folder available with the service user guide specific to Stocksbridge Neuro-Rehabilitation Centre. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means people who use the service experience adequate quality outcomes. On this inspection we found that the service did not always respond well enough to people’s dignity and welfare needs. Because of this the homes quality rating has reduced. This was a key inspection carried out by Shirley Samuels and Sue Turner on Tuesday the 12/08/08 from 9:45 – 15:30 In the report we make reference to “us” and “we”, when we do this we are referring to the inspector and the Commission for Social Care Inspection. The inspector sought the views of six people using the service, two relative four staff and the senior physiotherapist who assisted with the inspection. This visit was a key inspection and the inspector checked all the key standards. During this visit we looked at the environment, and made observations on the staffs’ manner and attitude towards people. We checked samples of documents that related to peoples support, care and safety. These included three assessments, care plans, three medication records, and three staff recruitment files. The inspector looked at other information before visiting the home. This included the Annual quality assurance assessment (AQAA). This is information provided by the service manager about how the service has developed over the last 12 months and what further changes are planed to improve. The inspector would like to thank everyone for their welcome and help in this inspection. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 7 What the service does well: People using the service and relatives acknowledged the good work done at the unit and spoke of transformation following treatment. Before moving into the service people had their needs fully assessed. This made sure that the staff had the information to make a decision about how people’s needs could be met. Each person receiving a service had a comprehensive care plan, which was reviewed and kept up to date. Due to the nature of some of the treatments and depending on the stage of recovery there were some restriction on people’s freedom to make choices and their own decisions. Risk assessments were completed and people were supported to take appropriate risk as part of developing independent living skills. The manager told us in the AQAA “we have previously developed links with learning and employment and would do so again if necessary”. “Daily routines in the home are designed to promote independence, individual choice and freedom of movement. People are able to maintain contact with family and friends however there are limitations placed on this depending on the recovery plan and needs of the individual. People told us that in the main they were satisfied with the food provided and there is evidence that people are offered choices. Records were kept of people’s health care needs and of appointments with health care professionals. People and relatives spoken to told us in the main they are satisfied with this element of their care. Staff told us they are trained and competent to administer medication. People told us they received their medication at the time they expected it. Records of complaints are kept and people told us their complaints are listened to and in the main acted upon. People told us they felt safe at the home. Staff told us they had received training on the protection of vulnerable adults and were able to tell us the action they would take if an allegation of abuse was made to them or if they witnessed an incident. Since the last inspection there has been one allegation of abuse. Since the last inspection there has been some replacement of carpets and redecoration. There are procedures in place to make sure cleanliness and hygiene is maintained. The procedure for recruiting staff is thorough and the records showed that procedures were followed. The records show that staff receive the training they need to do their job. People using the service are surveyed and asked to comment on the service. Staff were able to tell us what action they took on a daily basis to maintain a healthy and safe environment and to reduce the risk of injury to the people they support and to themselves. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 9 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 Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 10 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 and 2 People using the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. People are provided with information about the service and their needs are assessed before they move into the service. EVIDENCE: Information about the service was displayed in the entrance and on the units. People using the service and their relatives told us they were providing with information. This made sure that people using the service and people acting on their behalf had the information they needed to help them make a decision. Some of the information in the statement of purpose and the service user guide needed to be updated. This will make sure people get accurate and up to date information about the service. The records showed that people were assessed before being admitted. On the files comprehensive assessments, which detailed every aspect of need, were examined. This shows that people are assessed before moving into the service. This made sure that the staff have the information they need to make a judgement about the appropriateness of the service. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 People using the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. Each person has a plan of care, people are assisted to make decisions and take reasonable risks. EVIDENCE: Each person had a comprehensive care plan. Wherever possible the person using the service contributed to this. There was evidence that appropriate relatives also contributed. Care plans were drawn up in consultation with a dedicated team of therapist and other health professional’s specialist in specific areas, for example physiotherapist, Psychologist, speech and language and dietician. People using the service told us they were consulted and their representatives confirmed their involvement and in the care plan review. This makes sure that the care plan reflects the specific care and support needs of the individual their, aspirations goals and abilities. In the AQAA the manager told us that Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 12 care plan development had improved and identified further areas for development over the next 12 months. Staff gave us examples of how they encouraged people to make decisions for themselves. People’s ability to make choices varied depending on the stage of their treatment and recovery. Where people were unable to make decisions this was done in consultation with health professionals and the representative of the person using the service. People told us they were able to take reasonable risk. Risk assessments were seen on each of the files and were updated. Staff told us they provided appropriate and individualised levels of support to people in order to encourage independence and self-help. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 and 17 People using this service experience good quality outcome in this area This judgement has been made using available evidence including a visit to this service. People are able to take part in activities and develop and maintain links with the community. Links with family and friends is encouraged and managed to support wellbeing. There are some shortfalls in people’s satisfaction regarding the daily routines and the food provided. EVIDENCE: In the AQAA the manger told us “We have previously established links with adult learning and employment finding agencies and would do so again if necessary. Community visits, social and leisure activities are used as an alternative means to rehabilitation”, and “Daily routines and ‘house rules’ are designed to promote independence, individual choice and freedom of movement”. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 14 Support and advice was sought regarding personal relationships. Family and friends were able to visit. For some individuals visiting was limited and planned to ensure the wellbeing of the person and to reduce the risk of over stimulation. As part of the care plan people had an activities and therapy programme. The records showed that activities did take place and in the main people received their therapy sessions. There was evidence that there were gaps in these activities. Relatives and people using the service told us activities did not always take place as planned and felt that there was a lack of opportunity to take part in activities over the weekends. Some people Said their “therapy sessions have been cut”, others said “there is not enough to keep me occupied I get bored, there is not enough to do”. Staff were observed knocking before entering peoples bedrooms and addressing people in a friendly and appropriate way. People told us they were able to make choices about who they spent their time with and had free access to their bedroom and other communal parts of the home. We received mixed comments about the food provided. “In general the food is alright”, “we sometimes go out for meals” “There is a choice of meals” “ I get offered the same thing all the time for breakfast”. There was a four-week menu these were in small print displayed in the dining room. When I asked people using the service they did not know what was coming for lunch and the staff were unable able to tell me which week menu was current. Observations were made of the meals provided for lunch people were provided with different meals according to the choices they had made. They said they enjoyed it and that they were always given enough to eat. Staff told us for mealtimes they had a system for ensuring those who needed assistance was offered this appropriately and in a timely way. For people who need assistance are prompting with eating this was done in a sensitive way. Nutritional assessments were carried out and formed part of peoples plan of care. This means staff had the information they needed to make sure people received a diet suitable for their individual need. In the AQAA the manager told us “Account is taken of individual and cultural preferences. Snacks and drinks are available at other times. A Dietician and full time Speech and Language Therapist assist the kitchen and nursing staff in maintaining an appropriate and safe diet”. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 People using the service experience adequate outcomes in this area This judgement has been made using available evidence including a visit to this service. People experienced shortfalls in some of their personal care and some medication practices put people at risk of receiving medication errors. EVIDENCE: Peoples care plans detailed the support they needed and the action staff needed to take to meet people’s needs. However, the care plans made little reference to the maintenance of people’s privacy and dignity. People told us they did not feel their rights were always respected and gave examples of their dignity not being respected. This is not good practice and does not help to promote people’s rights. People using the service and their relatives told us that on regular occasions there were unacceptable delays in receiving a response to calls for help. On the day of the visit we observed a person waiting for 20 minutes before staff responded to the nurse call. This meant that people did not always receive the support they needed in a timely manner and left some people distressed and Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 16 uncomfortable. This is poor practice and does not support people to keep safe, dignified and comfortable. This could put people’s health and safety at serious risk, especially if their call is urgent. People told us in the main they were offered a shower on a regular basis, one person told us they had to “kick off” so they could have a bath. Better reference in people’s care plans about their privacy and dignity, choices and preferences, would support these situations better. People told us, and the records confirmed, that health needs were monitored and action taken to attend to peoples medical and health care needs. In the AQAA the manager told us “A local GP attends our weekly interdisciplinary team meetings and a Consultant in Rehabilitation Medicine visits at regular intervals and as necessary”. This makes sure that people’s health care needs are met. Medication trolleys were securely stored in a locked room. The staff responsible for the administration of medication told us they had received training and were competent to administer. In the main appropriate records were kept of the medication administered to people and people told us they received their medication at the time they expected it. Care plans detailed medication prescribed and there was evidence of medication reviews. However, we also found evidence that there were some poor practices that can put people at risk of receiving incorrect medication, and in turn affect their health. On one medication bottle it instructed administrator though a “PEG feed” the staff told us this instruction was out of date as the person was no longer being fed this way. Tablets were found in the trolley but not detailed on the medication administration sheet. This created a risk of medication not being administered as instructed. One relative told us they found tablets on the floor in the bedroom during a visit. There was a controlled medication being used, which had not administration instructions on the bottle. The label on another bottle of the same medication, which was almost empty, was illegible as over the period of being used wiping the bottle clean had destroyed the instruction. Yellow waste bins containing waste medication to be collected and destroyed were over flowing and insecure. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People using the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and people are protected from abuse. EVIDENCE: The home had a complaints policy and procedures that were detailed in information provided to people using the service. In the AQAA the manager told us that since the last inspection there had been no complaints made the home. People told us that in the main they felt their comments were taken seriously and actioned. Since the last inspection we have not received any complaints about the home. People told us they felt safe at the home. Staff were able to tell us what action they would take if an allegation of abuse was made to them. All staff had received training on safeguarding adults some staff were awaiting refresher training. Since the last inspection there has been one allegation of abuse at the home this was referred to adult safeguarding and the police. A prosecution is pending. This shows that action is taken to protect people and appropriate action taken when an allegations of abuse is made. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People using the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. The home was clean and reasonably maintained. EVIDENCE: Some areas of the home lacked interest and visual stimulation. Staff and people using the service told us that this was partially to do with not replacing things following decoration in addition to challenging behaviour, which resulted in property being damaged. The temperature in the Gym was recorded at 17 decrees centigrade and felt very cold. The light in the toilet near the gym was not working the staff said it had been like this for some time. The home does employ a person to carry out repairs. The staff told us that this system worked well for simple repairs and maintenance. Repairs referred to the organisations contractors’ took much Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 19 longer. On the day of the visit we were shown evidence that request had been made for several repairs to be completed. The staff raised concerns about the alarm attached to the fire exits being the same as the sound of the alarms for the emergency nurse call system. This could create confusion and prevent staff responding appropriately. The home was clean. Staff told us they were provided with cleaning materials and equipment to carry out their job safely and to promote good hygiene practice. The laundry was well equipped and the staff said all the equipment was in good working order. The majority of the staff have received training on infection control and were able to tell us what action they took on a daily basis to promote a good standard of hygiene. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33, 34 and 35 People using the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. People receive care and support from trained and competent staff. EVIDENCE: In the main the people using the service and their relatives spoke positively about the staff and the outcome of the treatment provide at the home. People felt the staffing levels were not always enough to meet their needs. Relatives confirmed this and said it was “particularly bad at some weekends”. People told us on occasions therapy sessions were cancelled due to staff shortages. Comments received about the staff included “some staff quite nice”, “some a bit crap don’t treat me as an adult”, “and there are a lot of staff leaving”. One relative said the treatment received is “brilliant”, “Sometimes can’t find staff, they take a long time to come and most of the staff are very keen”. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 21 People using the service told us they appreciated the staff sometimes “have a difficult job” and added “they do a marvellous job”. The rotas showed that there or shifts where the staffing level required was not being maintained. Staff told us there had been some delays in recruiting to staff vacancies but that in recent weeks a decision had been made for recruitment to take place. In the AQAA the manager told us “Staff are aware of their responsibility to make themselves available for training to develop their knowledge, skill and understanding” and “all staff receive structured induction training, foundation and role specific training. This makes sure that staff develop the skills they need to meet the needs of the people they support. There is a strict recruitment procedure in place. Checks are carried out on applicants before they start work. Criminal checks and references are completed. This promotes the protection of people using the service. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41 and 42 People using the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. People live in a home that is well managed. EVIDENCE: The service manager, who completed the AQAA and who is based at the home, told us “The registered person is qualified and experienced, having a Registered Managers Award. The staff told us the registered manager was approachable and supportive. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 23 The service manager told us “The registered manager is supported by the Clinical Lead for the Interdisciplinary Team, (the Group Consultant Clinical Neuropsychologist), a Social Work qualified Service Manager, a Specialist Speech and Language Therapist, Lead Physiotherapist and Lead Occupational Therapist”. The records showed that meetings were held where people using the service and their relatives were able to comment on the service they were receiving. We were told that people using the service completed questionnaires. These were sent to head office. At the time of this visit there was no evidence of feedback from this survey. This meant that the outcomes of audits were not published. On the day of the visit we saw a number of peoples files containing information about them on the corridor floor outside their bedrooms. This compromised peoples right to confidentiality, and did not respect their dignity. Staff had received training and equipment was provided for moving and handling. There was a fire risk assessment in place put this was not updated. Records of accidents were recorded and details of action taken to reduce risk to people were seen. Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.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 3 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 3 x 3 x 3 3 x Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 YA18 Regulation 12 Requirement People’s health, safety, dignity and comfort are put at risk when staff do not respond to their calls for assistance in a timely manner. This practice must improve to ensure peoples safety and welfare. Poor medication practices, which put people’s safety, health and wellbeing at risk, must improve. This must include: Medication instructions must be clear and up to date Safe storage of all medicines Timescale for action 20/09/08 2 YA20 13 20/09/08 Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 26 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 YA1 YA16 Good Practice Recommendations The statement of purpose and the service user guide should be updated to make sure it reflects changes in the service and information about external agencies. Consideration should be given to the comments of the people using the service and heir relatives about the lack of activities at the weekend and appropriate action taken to respond to this. Consideration should be given to the comments made about the meals provided and action taken to respond to this. People’s care plans should have better information about their preferences and needs on privacy and dignity. This will help to protect people’s rights better. 5 YA24 To make sure people are not placed at unnecessary risk There should be a review of the procedures for obtaining repairs needed to be carried out by contractors to make there are no unnecessary delays. Action should be taken to make sure that staff are alerted appropriately to the opening of fire doors and to the summoning for assistance from people using the service. To ensure the health and welfare of people using the service. There should be enough staff on at all times to met peoples needs. To inform people about the service. The outcomes of audits should be published. Records should be stored in a way, which ensures peoples right to confidentiality. To ensure the safety of people using the service and the staff the fire risk assessment should be updated and detail the action needed to maintain a safe environment. 3 4 YA17 YA18 6 7 8 9 10 YA24 YA33 YA39 YA41 YA42 Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Stocksbridge Neuro-Rehabilitation Centre DS0000048612.V368799.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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