Inspection on 08/11/06 for The Old Post Office Residential Home

This inspection was carried out on 8th November 2006.

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 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

The Old Post Office Residential... 22/05/07

The Old Post Office Residential... 25/01/06

The Old Post Office Residential... 27/07/05

The Old Post Office Residential... 03/03/05

The Old Post Office Residential... 05/07/04

The Old Post Office Residential... 15/03/04

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Polesworth Group Friary Road

Polesworth Group Pooley Heights

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Polesworth Group 70 Long Street

Breme

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Polesworth Group 68 Long Street

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

CARE HOME ADULTS 18-65 The Old Post Office Residential Home Newport Road Haughton Stafford ST18 9JH Lead Inspector Dawn Dillion Key Unannounced Inspection 8 November 2006 09:45 The Old Post Office Residential Home DS0000057119.V318170.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 The Old Post Office Residential Home DS0000057119.V318170.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. The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Post Office Residential Home Address Newport Road Haughton Stafford ST18 9JH 01785 780817 01785 780883 kevin.betts@btinternet.com / joetopoh555@hotmail.co.uk The Old Posting Office (Haughton) 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) Care Home 5 Category(ies) of Learning disability (5), Mental disorder, registration, with number excluding learning disability or dementia (5) of places The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All five service users to have a learning disability Date of last inspection 25 January 2006 Brief Description of the Service: The Old Post Office is a residential home located in Haughton, Stafford having easy access to public transport and local amenities. The home provides a service for adults of both genders who have a learning disability and a mental disorder. The two-storey detached property is situated within its own grounds; all bedrooms are of single occupancy equipped with en suite. Toilets and bathrooms are located throughout the home and are in close proximity to bedrooms and communal areas. The design and layout of the property would not be suitable for individuals who have a physical disability; there are no specialist equipment or passenger lift in place. The home provides a large lounge and separate dining area that is pleasantly decorated and equipped with essential furnishings and items to provide a comfortable area. Service users have access to a large domestic style kitchen; a separate laundry area is also provided. Limited car parking is provided at the rear of the property. The home offers a well-maintained garden, which is accessible to all service users. Staffing is provided within the home on a 24-hour basis, to ensure the total supervision and support of the individual service user. The fee chargeable for the service at The Old Post Office is £1,575.00p per week. The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced Key Inspection of The Old Post Office was undertaken in ten hours over two days. The inspection methodologies that were used to establish the quality of care provided and the effectiveness of the management of the home, to promote quality, diversity and best practices entailed the examination of the records relating the homes policies and procedures. Four service users were interviewed to ascertain their views and opinions of the service provided and the level of support and guidance offered, to ensure that they were able to live a lifestyle, of their choice with regards to their cultural and specific needs. Information was collated from comment cards received from service users and health and social care professionals. A tour of the property was also undertaken to ensure that the environment and systems in operation were safe and conducive in meeting the needs of the service user group. What the service does well: What has improved since the last inspection? There were no requirements identified at the last inspection visit on 25 January 2006. It was pleasing to see that recommendations identified at the last inspection visit, with regards to the commissioning of training for staff through The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 6 the Learning Disability Ward Framework (LDAF) and the installation of paper dispensers had been addressed. 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. The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 7 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 The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 8 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): 2 Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. The quality in this outcome area is “adequate.” This judgement is based on the examination of records pertaining to a service user who had recently been admitted to the home. Prospective service users were provided with the necessary information and support prior to moving into the home, to enable them to establish whether the home and service provided would be suitable to meet their identified needs. EVIDENCE: The home had one new admission since the last inspection visit, the examination of records, identified that the service user was provided with the necessary information and support, prior to moving into the home. To enable them to establish whether the home and service provided would be suitable to meet their identified needs. The examination of the service user’s file identified that a pre admission assessment was undertaken, to establish the prospective service users care The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 9 and social needs, information obtained from the pre admission assessment provided a foundation for the development of the care plan and risk assessment. Discussions with the Acting Care Manager confirmed that prospective service users were encouraged to visit the home prior to their admission, giving them an opportunity to view the premises and to meet existing service users and the staff team. The Acting Care Manager informed the Inspector that existing service users were involved in the decision to whether prospective service users would be suitable to live in their home. The examination of records pertaining to the homes admission procedure did not identify, that written confirmation was given to the prospective service user or their representative of the homes suitability to meet their care needs. The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. The quality in this outcome area is “good.” This judgement is based on information obtained from the examination of care plans, risk assessments, minutes of service users meetings, discussions with service users and general observations during the process of the inspection. Service users were provided with the necessary support and guidance to live a lifestyle of their choice and to have positive life experiences. The home was proactive in promoting service users rights and choice. Risk assessments provided a basis to assist service users in taking risks to promote normal daily living. The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 11 EVIDENCE: Information obtained during the process of the pre admission assessment, provided the foundation for the development of the care plan. Service users were encouraged to participate in the development of their plan of care and subsequent reviews. The care plans provided in-depth information with regards to the care needs of the individual service user and the level of support required to enable them to live a lifestyle of their choice and to have positive life experiences. Consideration should be given in ensuring that care plans include information relating to the necessary intervention of other social and healthcare professionals. Consideration should be given in providing care plans in a format that are more user friendly and promotes the understanding of the service users group. Discussions with the Acting Care Manager identified that a number of service users do at times display aggressive behaviours; the care plan provided information in relation to re-directive techniques and physical intervention. Staff training records identified that staff had received training within this area. There was a positive emphasis focused on service user choice and rights, discussions with service users and general observations during the process of the inspection, identified that service users were able to have a choice with regards to daily activities. The service provided at The Old Post Office was flexible to meet the needs of the individual service user. The examination of minutes of service users meetings identified that these meetings were undertaken on a regular basis. During these meetings service users were encouraged to participate in areas affecting the service provided within the home. The home also operated a comments book, which was also accessible to non-service users. The Acting Care Manager informed the Inspector that service users had access to a self advocate if and when necessary. A risk assessment was in place for the individual service user, providing information relating to potential hazards and the appropriate control measures to reduce or eliminate the identified risk. With reference to the new fire regulations, the Acting Care Manager should incorporate within the risk assessment, information relating to the level of support and assistance the individual service user would require to enable them to evacuate the building in the event of a fire. The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. The quality in this outcome area is “good.” This judgement is based on information obtained from activity programmes, discussions with service users and the examination of menus. Service users had access to various social activities in the home and within their local community. Staff provided service users with the necessary support to ensure that they were able to maintain a relationship with their family and friends. Menus were varied to reflect the likes and dislikes of service users. The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 13 EVIDENCE: Service users attended the local colleges to develop and learn new skills, discussions with service users identified that they attended the following courses: music and movement, art and craft, media, managing money, creative skills, sport and healthy living. There were no service users in paid employment; discussions with one service user identified some interest of obtaining future employment. As previously identified within the contents of this report, there was a positive emphasis focused on social inclusion, providing service users with the necessary support to access facilities within their community. Two service users that were interviewed confirmed that they were registered on the electoral roll and were able to pursue their political interest, if they so wished, both service users informed the Inspector that they were not interested in politics. The Acting Care Manager informed the Inspector that there were no service users within residence that had any cultural or religious needs but confirmed that the home would be able to adapt the service to meet the needs of any prospective service user from the minority groups. One service user informed the Inspector that he intended to start going to church and was able to access the local church independently. Service users had access to various social activities in the home and within their local community. The home had its own transport and service users informed the Inspector of trips to Wales, Blackpool, Telford Park and Buxton. Social activities also included camping, walks, barge trips, cinema and access to the leisure centre. The Acting Care Manager informed the Inspector that home funded 50 of service users annual holiday. Staff provided service users with the necessary support to ensure that they were able to maintain a relationship with their family and friends. One service user confirmed that he had regular contact with his family who were able to visit the home at anytime. The daily routine within the home was relaxed with service users having access to all facilities with limited restrictions due to the health and safety. All bedrooms doors were fitted with a locking device to promote the privacy of service users, three service users were in receipt of a key. The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 14 Service users were responsible for maintaining the cleanliness of the home and were provided with the necessary support and assistance by staff. The examination of menus identified that a varied diet was provided with regards to the individuals’ likes and dislikes. Discussions with the Acting Care Manager identified that there were no service users in residence, with any specific dietary needs or requirements for specialist equipment. The examination of medication mar sheets identified that two out of five service users were prescribed laxatives. Advice should be obtained from a dietician to promote healthy eating, in view of reducing the need for regular laxatives. The Old Post Office Residential Home DS0000057119.V318170.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 Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. The quality in this outcome area is “adequate.” This judgment is based on information obtained from care plans; discussions with service users and the examination of medication mar sheets. Staff were very committed in providing a high standard of care to service users, there was however, a lack of intervention of relevant health and social care professionals with regards to the management of challenging behaviours. The homes medication practices were not entirely robust to ensure the welfare of service users. EVIDENCE: As previously identified within the contents of this report, a care plan was in place for the individual service user, providing information relating to their care The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 16 needs and the level of support required to ensure that they were able to live a lifestyle of their choice. Discussions with the Acting Care Manager confirmed that all service users within residence were mobile and there were no requirements for moving and handling. It is recommended that staff receive refresher training relating to moving and handling. The examination of records identified that there was no intervention of relevant health or social care professionals, specialised in learning disabilities with regards to the management of challenging behaviours. The emphasis focused on the management of challenging behaviours was re-directive techniques and drug therapy. There were no structured behaviour programmes in place, to identify the reasons surrounding anti social behaviours. The home did maintain a record of all incidents of anti social behaviours. All service users were registered with a General Practitioner and records pertaining to service users evidenced that they had access to ophthalmic and dental treatment and was also offered an annual well persons health check. The home operated the Boots monitored dosage system; the Registered Manager informed the Inspector that there were no controlled drugs or homely remedies in use. The Inspector raised concerns that there were no protocol in place, to identify when and what PRN (when required) medication, should be administered, or the timing between dosages or the appropriate actions to be taken should the challenging behaviour continued when the maximum dosage had been administered. Discussions with the Acting Care Manager identified a lack of knowledge to the reasons why one service user was prescribed an anti epilepsy drug, who had no history of epilepsy. There was also a lack of knowledge with regards to the side affects of drugs that were prescribed. The Acting Care Manager informed the Inspector that one service users’ current symptoms had developed since starting a new drug. The Old Post Office Residential Home DS0000057119.V318170.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 Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. The quality in this outcome area is “good.” This judgement is based on the examination of the homes complaints procedure and systems in operation to enable service users to share their concerns relating to the service provided to them. The home was in receipt of the Staffordshire Inter Agency Vulnerable Adults policy. The homes recruitment procedure ensured that the appropriate safety checks were undertaken to protect the service users. EVIDENCE: There was a complaints policy in place; the Acting Care Manager should ensure that this policy is accessible to all service users. Consideration should also be given in producing this policy in a more user friendlier format to promote the understanding of the individual service user. The home was in receipt of the Staffordshire Inter Agency Vulnerable Adults policy. The Acting Care Manager should ensure that all staff have access to this policy. The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 18 The home also operated a comments book to obtain service users and relatives’ views in relation to the service provided within the home. The examination of this book identified very positive comments with regards to the service delivery. The homes recruitment procedure ensured that all prospective staff were subject to the appropriate safety checks prior to the commencement of employment. Physical intervention was used within the home, discussions with the Acting Care Manager and the examination of training records identified that staff had received training within this area. With reference to service users finances, all service users required some element of support with their financial affairs. Three records and funds pertaining to service users were examined on the day of the inspection, all of which were satisfactory. The Old Post Office Residential Home DS0000057119.V318170.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. 24 and 30 The quality in this outcome area is “good.” This judgement is based on general observations during the tour of the premises. The property was suitable to meet the needs of the service user group, having access to all facilities within the home. EVIDENCE: The Old Post Office is located in the village of Haughton, Stafford having easy access to public transport and local amenities. The property was suitable to meet the needs of the service user group, having access to all facilities within the home, with limited restrictions due to health and safety. The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 20 The mature two-storey detached property is situated within its own grounds; all bedrooms were of single occupancy equipped with en suite. Toilets and bathrooms were located throughout the home and were in close proximity to bedrooms and communal areas. The design and layout of the property would not be suitable for individuals who have a physical disability; there are no specialist equipment or passenger lift in place. The home provided a large lounge and separate dining area that were pleasantly decorated and equipped with essential furnishings and items to provide a comfortable area. Service users had access to a large domestic style kitchen; a separate laundry area was also provided. Limited car parking was provided at the rear of the property. The home offered a well-maintained garden, which was accessible to all service users. The property was well maintained and was in keeping with the local community. The hygiene and cleanliness within the home was good. The Old Post Office Residential Home DS0000057119.V318170.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. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 25 Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. The quality in this outcome area is “adequate.” This judgement is based on information obtained from the staff rota and discussions with a number of staff. The homes recruitment procedure ensured that all prospective staff were subject to the relevant safety checks prior to the commencement of employment. The staffing levels were adequate to meet the identified needs of the service user group. Staff training matrix identified that refresher training in areas that promote good practices was required. The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 22 EVIDENCE: The examination of a file pertaining to a staff member identified that the homes recruitment procedure ensured that all prospective staff were subject to the relevant safety checks prior to the commencement of employment. The examination of records pertaining to staff training identified that food hygiene and moving and handling training had not been undertaken within the last twelve months. It has been identified as a requirement that staff should complete their infection control training of which they have already commenced. It was pleasing to see that Learning Disability Award Framework accredited training (LDAF) has identified as a recommendation within the last inspection report had been completed. The Old Post Office Residential Home DS0000057119.V318170.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. The quality in this outcome area is “adequate.” This judgement is based on discussions with the service users, Acting Care Manager and care staff. The homes quality assurance systems were examined. Records and systems that promote the health, safety and welfare of both service users and the staff team were examined. The management approach was open and transparent, actively involving both the service users and staff in the running of the home. Some practices within the home did not promote health and safety. The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 24 EVIDENCE: The Registered Manager for the Old Post Office had recently left, during the interim period an Acting Care Manager had been appointed to undertake the management of the home during the recruitment process. Discussions with the Acting Manager confirmed that she was experienced within social care and had recently obtained the Registered Manager Award. With reference to systems in operation with regards to quality assurance, the home operated a comments book and monthly audits were undertaken. The Commission For Social Care receives regular regulation 26 visit reports. Records that were examined with regards to the health, safety and welfare of both the service users and staff group identified the following: A fire risk assessment was in place, in conjunction to the new fire regulations; the Acting Care Manager should ensure that the risk assessment contains information relating to fire evacuation. The last record fire alarm test was 08/11/06. The fire equipment was last checked 05/11/06. The last recorded checks for emergency lighting was 05/10/06. There were no records maintained of fire drills. Portable Appliance Testing (PAT) was undertaken by the homes handyperson, the Acting Care Manager should ensure that this person is suitably qualified to undertake theses safety checks. With regards to health and safety, the Inspector raised concerns that flammable chemicals were stored in the cellar; this has not been identified as a requirement, within the contents of this report, due to that fact that these items were removed during the process of the inspection. The Acting Manager should ensure that personal protective equipments (PPE) are accessible within the laundry area and that staff have access to the hand wash facility. (This was addressed on the day of the inspection). In view of the service user group and to promote their safety, wall units within the home should be secured to the walls. The Old Post Office Residential Home DS0000057119.V318170.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 X 2 2 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 X 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 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 The Old Post Office Residential Home DS0000057119.V318170.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 YA42 Regulation Requirement Timescale for action 01/12/06 23(4)(c)(iii) With reference to the new fire regulations, the risk assessments should incorporate information relating to the level of support and assistance the individual service user would require enabling them to evacuate the building in the event of a fire. 16(2)(i) and 13(1)(b) The Registered person should ensure that service users have access to a dietician to promote healthy eating, with an aim to reduce the need of regular prescribed laxatives. Food hygiene and infection control training should be commissioned for the staff. The Registered person should ensure that service users have access relevant health and social care professionals specialised in learning disabilities with regards to the management of challenging behaviours. The Registered person should ensure that there is a written DS0000057119.V318170.R01.S.doc 2 YA17 03/01/07 3 4 YA35 YA19 18(1)(c)(i) 13(1)(b) 02/02/07 15/12/06 5 YA20 13(2) 15/12/06 Page 27 The Old Post Office Residential Home Version 5.2 6 YA20 18(1)(c)(i) 7 YA42 13(4)(a) protocol in place to identify when and what PRN (when required) medication should be administered, the timing between dosages or appropriate actions that should be taken if the challenging behaviour continues when the maximum dosage has been administered. Staff members who are responsible for the administration of medicines should receive further training with regards to the safe handling of medicines. The Registered Person should ensure that the Handyperson is suitably qualified to undertake portable appliance testing (PAT). To ensure that all wall units within the home are secured to the wall. The registered person should confirm in writing, to the service user or their representative, of the homes suitability for the purpose of meeting their needs in respect of their health and welfare. 02/02/07 23/12/06 8 9 YA42 YA2 13(4)(a) 14(1)(d) 23/12/06 01/03/07 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 YA6 Good Practice Recommendations Consideration should be given in ensuring that care plans include information relating to the necessary intervention of other social and healthcare professionals. Care plans should be developed in a format that are more DS0000057119.V318170.R01.S.doc Version 5.2 Page 28 2 YA6 The Old Post Office Residential Home 3 4 YA42 YA35 user friendly and promotes the understanding of the service users group. A record should be maintained of all fire drills undertaken within the home. To promote best practice consideration should be given in providing moving and handling training on an annual basis. The Old Post Office Residential Home DS0000057119.V318170.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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