Inspection on 24/10/07 for Trinity House

This inspection was carried out on 24th October 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 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

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Dilston College Of Further Education

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Park View (15)

Craigmore House

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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 Trinity House Knaresborough Road Murton County Durham SR7 9RQ Lead Inspector Ms Kathy Bell Unannounced Inspection 24th September 2007 10:30 Trinity House DS0000069669.V351051.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 Trinity House DS0000069669.V351051.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. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trinity House Address Knaresborough Road Murton County Durham SR7 9RQ 0191 517 3413 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) trinity@swantoncare.com Autism North Limited Denise Grufferty Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Learning Disability - Code LD, maximum number of places: 6 The maximum number of service users who can be accommodated is: 6 First inspection Date of last inspection Brief Description of the Service: Trinity House is registered to provide care (but not nursing care) for six adults over 18 with learning disabilities. The home is allowed to provide care for someone over 16 at the moment. It is a service specially for people with autism and was first registered in April 2007. Trinity House is a large detached building with a big garden. It provides plenty of space for residents, with two large living rooms and a dining room. All the bedrooms are single and each has its own bathroom with a bath or shower. The fees charged for this service are based on individual needs. The company did not wish to make this information available in a public report but the individual fees are written down in correspondence with the local authorities who buy the service. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place during one day in September 2007. It was the first inspection since the home opened. The home was given one days notice of when the inspection would happen, so that they could prepare residents who might be uncomfortable with an unexpected visitor who they did not know. During the inspection, the Inspector saw most residents and talked in depth to one of them. She talked with the manager and two of the staff. Four relatives, one care manager and three staff filled in surveys. The inspector also spoke to two relatives after the visit to the home. What the service does well: What has improved since the last inspection? What they could do better: The home must obtain a copy of the care managers assessment for each resident before they are admitted. This will help them be sure they can meet the residents needs and make sure that all the arrangements for continuing healthcare etc are in place. Care plans must always be kept up-to-date to make absolutely sure that staff have the information they need. Guidelines for responding to behaviour must include detailed information about what may make each person upset or angry, how staff should try and avoid this happening and how staff should respond if the resident has become upset. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 6 If a residents weight needs to be monitored, staff must record each time they are weighed. Care plans must include written guidelines on how medication is given to someone, when special instructions are needed. The manager must check current Health Authority guidelines on training required for staff to give out emergency medication for seizures. The manager must get a copy of the local area guidelines on child protection, to make sure they know what they are expected to do if there are any concerns about resident who is under 18. The manager must check if noise from the laundry can be heard in the bedroom above. If it is noisy, the laundry must not be used at night. Records must be kept of the training each person receives. All staff must complete training in food hygiene and first aid as soon as possible. The company which runs the home must keep checking that the manager has time for record-keeping and other management tasks. Staff must record regular checks of the temperature of hot water at any taps used by residents. They must record checks of the safety of bedrails and wheelchairs. The boiler cupboard in the dining room must be kept locked. The manager should ask for information about how emergency medication for seizures can be given to be included in the type of care plan used locally. This format of care plan sets out clearly who has been trained to do this and who has consented to the use of this medication. 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. Trinity House DS0000069669.V351051.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 Trinity House DS0000069669.V351051.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): Standard 2. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home obtains detailed information about each new resident so staff can be sure they will be able to meet their needs. But this should include the care managers assessment. EVIDENCE: Residents parents had filled in a very detailed information form, before each resident was considered for admission. This included information about their history, behaviour, health, diet, likes and dislikes, care needs and daily routines. This is an excellent way of getting the information staff need to care for people well. The manager described how she visits and assesses people. Care managers had assessed people before they were admitted but copies of their assessments were not available in the home. The home must get these, so that they are aware of everything they need to know. This would also help them make sure that all arrangements are in place, as far as possible, to meet peoples needs when they move into the home. A care manager said that, initial assessment and introduction/transfer to service was very good. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 9 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): Standards 6, 7 and 9. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents have care plans which explain the care they need. Although staff seemed aware of changes, the care plans must always be kept up-to-date. Residents can make choices about their daily lives and are kept safe, without their independence being restricted. EVIDENCE: Each resident has a care plan which explains what staff need to do for them. The resident who only moved in a few days ago has not got a full care plan yet but staff have a lot of information already on his personal care needs, behaviour and routines. The manager described how staff use the detailed daily records they keep to bring together all the information into a care plan. Staff record that they review the care plans each month. The care plans include information about health, personal care needs, leisure interests, likes and dislikes, etc. The records staff used most in their day-to-day work had not always been updated to show exactly what they should do. But staff said in their surveys that the systems for passing information between staff usually or always worked well. Everyone is aware of anything regarding service users, i.e. through staff meetings or handovers. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 10 Records showed that the staff had received specialist advice on how best to manage one residents behaviour. This advice included explanations of what might be causing the behaviour. Although the manager and staff could explain the various ways they tried to avoid the resident becoming upset or angry, they did not have formal written guidelines. These guidelines, for each person who needs them, should describe what may make them upset or angry, how staff can avoid that happening, what staff should do to help them calm down, and what staff can do if they do need to physically restrain them. Some staff knew that they were not all acting consistently with one resident and that they needed to all agree guidelines. But despite this, records and comments from a relative suggest that they are being successful in helping this person avoid upsetting incidents. Records showed and the Inspector saw that residents were able to make choices about their daily lives, such as whether to take part in activities, how they wanted their rooms and when to get up in the morning. But sometimes staffing levels have meant that someone has to go out with the group when they would rather have stayed at home. The home aims to increase staffing so that this will not be a problem in the future. A resident talked about the activities he was planning with staff and how he had chosen what colour to have his bedroom painted. When asked in the survey does the service support people to live the life they choose?, three of the relatives said always, and one said usually. Staff record when they have looked at the risks which may be involved in residents taking part in activities, going out and about and doing things independently. These risk assessments explain the support staff need to offer to help people do these things safely. Staff said that they follow these guidelines. For example, if the risk assessment says that two staff must go out with someone, then two staff are made available. Staff were recording that they review these risk assessments each month. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 11 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): Standards 12, 13, 15, 16 & 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Residents have active and interesting lives and can choose what they want to do, whether using special facilities or the local community. They can keep in contact with their families. The home recognises residents rights and they are encouraged to take responsibilities in their daily lives. The home tries to provide a varied and healthy diet, within the limits of what residents will accept. EVIDENCE: Each resident has a weekly activity plan. This includes a range of activities such as trampolining, bowling, swimming and attending Autism Norths own day centre. But people also had time for their own choice of activities, such as going to a football match for one resident, and for simply relaxing. People go out and about in the local area, one resident is planning long walks and a parent described simple but enjoyable activities such as going for a walk and picking blackberries. The manager described how they include education as part of daily life, for example working on numbers by dealing with money when shopping. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 12 Residents have regular contact with their families-for some it is their first move away from home. Parents said, my son asks to ring me whenever he wishes and always welcoming, very amenable when we wish to bring our son home. They also said that they were kept up-to-date with important issues affecting their children. All the homes policies and procedures emphasise the rights of residents. Important information is provided in a way which makes it easier to understand. Residents are encouraged to take responsibility for daily life in the home, keeping their rooms tidy, helping in the kitchen etc. One resident said that he helped staff with the safety checks in the home. In the information provided before residents moved into the home, parents provided a list of likes and dislikes about food. This helps the home provide meals which residents will enjoy. One resident said that he did have choice in what he ate and the Inspector saw one resident go into the kitchen and help himself to a second helping. Some residents are reluctant to eat a balanced diet but the home is working to try and improve this, without upsetting them. Staff keep records of what each resident has eaten so they can monitor if they are eating enough. The Manager believes that staff are weighing residents weekly, where this is needed, but they had not been recording this. The home is going to advertise for a member of staff to act as housekeeper and cook. This is a good idea, as it means that one person takes main responsibility for planning meals and food hygiene. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 13 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): Standards 18, 19 & 20. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People receive a good standard of personal care and the home is working on arrangements to make sure that all healthcare needs are met. Arrangements for looking after medication seemed generally satisfactory but the home should have clearer guidelines on giving out medication with food and on giving emergency medication if someone has a seizure. EVIDENCE: Very detailed guidelines on how each person needs help with personal care are available for staff. For some people, the emphasis is on encouraging independence, respecting privacy, while making sure they are looking after themselves well enough. There are policies to guide staff on how to respect people when providing personal care. In surveys, three staff who replied said they were always given up-to-date information about peoples needs and that the systems for passing information between staff always or usually worked well. Everyone is aware of anything regarding service users, i.e. through staff meetings or handovers. When asked in the survey, Does the home give the support or care that you expect or agreed?, three relatives who responded said always. As my daughter is always happy when I visit or collect her, it shows me that she is receiving excellent care. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 14 Some residents can have difficulty controlling their behaviour when they become upset or angry. Staff have had training in how to reduce the problems this can cause for people, and how to respond to them. Staff keep the records which they must keep about the occasional times when staff have had to restrain someone. These show that they only do this when it is necessary for someones safety and that it is not happening as often, as they have got to know people better. The home has referred one resident to a speech and language therapist to try and make it easier for her to communicate and say what she wants. Her mother commented that staff have done well, as it is difficult to interpret how she communicates. Staff have completed a full assessment of health needs for each resident. They keep records of visits to GPs and the advice given. There are also records of when the home has consulted specialists such as the psychologist or psychiatrist. The manager explained that she is trying to set up local dental and optician services for residents. There has been a delay in arranging physiotherapy for one resident as she came from another area. This is not the homes fault. But it shows the importance of a full assessment before admission, so that arrangements can be made to meet all a persons needs when they move to a new area. The home has generally satisfactory systems for storing and giving out medication. There are records of medication returned to the pharmacist and of when medication is taken in and out of the building. But a review on one resident mentioned medication administered in food. The manager explained that it was not crushed up in food (this can be unsafe) but medication was given with food, to help that person swallow it. This is satisfactory, but needs to be explained clearly in written guidelines. One resident is prescribed emergency treatment for seizures. The doctor who prescribed this has provided clear guidelines on how this can be used. But the home should ask for the type of care plan agreed for use in this area, which says clearly who has been trained to give this drug and who has agreed to this. This makes sure that everyone responsible for someones care has agreed on how it can be given. The manager should also check current Health Authority guidelines on who can provide training on this. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 15 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): Standards 22 & 23. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has done all it can to make sure people feel able to complain. Residents are protected from abuse. EVIDENCE: The home has a satisfactory complaints procedure. There is a simpler version with pictures for residents who may understand this better. And there is a picture pinned up each room reminding residents about telling people if they are unhappy. The manager had recorded properly when a relative raised a concern and the action that had been taken. In the surveys, three relatives said they knew how to make a complaint and one couldnt remember. The two who commented on this, said that the home had always responded appropriately to concerns. Proper records are kept of any money looked after for residents. Staff keep receipts and two staff sign when money is used. But there should be a procedure to make sure staff know how to account for money spent, and what residents personal allowances can be used for. In most cases, relatives still look after residents benefits, but one resident has his own bank account. During the training they receive when they start work, staff have training on what is considered abuse and what to do if they think someone is being abused. The company which runs the home has satisfactory procedures about what must be done if abuse is suspected, and a whistleblowing procedure, which supports staff to speak up if they think something is wrong. Staff receive training in restraint which has been approved by the British Institute for Learning Disabilities. This is the standard of training which is recommended for care home staff. The training explains residents rights, and Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 16 how staff must do all they can to reduce the times someone may become so angry and upset that they need to be restrained. They keep proper records of times when this has been necessary and these show how staff have only used restraint as a last resort to protect someone. As the home has a resident under the age of 18, they must have a copy of the local area arrangements for child protection, to make sure they know what is expected of them. The manager has been unsuccessful so far in obtaining this. New staff are checked to make sure that they are suitable people to work with vulnerable adults. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 17 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): Standards 24 & 30. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home provides a safe, clean and pleasant place to live, which meets peoples needs. EVIDENCE: Trinity House is a large detached building, with an enclosed garden and plenty of space around it. There are two living rooms, a dining room, kitchen, office and the laundry. A toilet has also been provided for the use of visitors who may have mobility problems. Each resident has their own bedroom, with an ensuite bath or shower. A suitable shower, handrails etc have been provided for a resident who needs these adaptations. Some of the bedrooms are very large and residents have been able to fill them with their own possessions and make them personal to them. The building was completely redecorated before the home opened in spring and decoration and furnishings are of a good standard. One bedroom is above the laundry: the manager must check if the resident might be disturbed by noise if the laundry is used at night. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 18 The home seemed clean on the day of inspection. There were supplies of protective equipment, gloves and aprons, to help staff prevent the spread of infection. Staff receive basic training in infection control when they start work. There was a list of cleaning tasks to be done, which staff had to sign when they had completed them. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 19 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): Standards 32, 33, 34 & 35. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Staff have, or are learning the skills and knowledge to work with people with autism and more than half the staff have the qualification recommended for care workers. Staffing levels are high, as they need to be to provide a good level of care. The company carries out checks before people start work, to make sure, as far as they can, that they will be suitable to work in the home. There is a good training programme for staff but not all staff have yet had training in basic areas such as food hygiene. EVIDENCE: Some of the staff have had considerable previous experience in care homes for people with autism. Nine of the 16 care staff have a NVQ 2 in care, which is the recommended qualification for care workers. The National Minimum Standards for care homes recommend that half of the staff have achieved this so the home has already met this standard. A relative commented that staff were pleasant and friendly, nothings a trouble to them. She also said that they had gone out of their way to support relatives during the difficult time when a young person is making the move from their home to a care home. A resident said that the staff were nice. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 20 During weekdays, the manager is on duty from 8 a.m. to 4 p.m. and three or four staff are at work until 4 p.m. (although one is making meals). Until the weekend before this inspection, there were only four residents, and some residents went home at weekends, so staff were able to manage with only two staff on duty at times at weekends. The manager described how they plan to have four staff on duty during the week and three at weekends, now they have a fifth resident. They are also advertising for a housekeeper to take the main responsibility for meals, which will free time for care staff. At night there are two staff awake on duty. The staffing levels seem high enough to provide a good level of care and individual attention and activities for residents. The company has an established system for carrying out Criminal Records Bureau/POVA checks before people start work, to make sure they will be safe to work in the home. They also obtain references. The records of the training each person has done had not been kept up-todate. Many of the staff have benefited from full training provided in their previous jobs. This has included all the basic training such as first aid and food hygiene, and more specialist training on the needs of residents with autism. The company provides training for new staff, with a workbook for them to complete. This includes training on autism awareness, equality and diversity, health and safety including infection control, moving and handling and food hygiene, adult protection and whistleblowing. This seems to be a good standard but because a number of new staff started work at once and could not be released for training at the same time, they have not all completed this training package. However the manager takes this into account when she considers the work people are going to do. For example, although new staff have not all had first aid training, they do not take residents out on their own. The company is going to employ a training manager to help organise training for staff in the future. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 21 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): Standards 37, 39 & 42. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The manager has the experience and qualifications to run this home but her company needs to make sure she has enough time for the management side of her role. Arrangements for protecting the health and safety of residents and staff are satisfactory in most ways. Staff are still developing systems to help the home make sure it provides the service which people expect. EVIDENCE: The manager previously managed another small home for people with autism, run by the same company. She has obtained the recommended qualifications for managers of care homes. She has been honest about the challenges of starting a new home and building a team of people to work together. She feels she has received good support from her line manager in this. But these demands have meant that she has needed to spend more time working with staff and new residents. She has had less time to spend on paperwork in the office. The company which runs the home accepts that managers need more Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 22 support and they are employing other staff to take some of their office work away from them. Staff said that they felt able to raise any issues with her. The building has been completely renovated and fitted with low surface temperature radiators, a fire safety system and restrictors on windows. The temperature of hot water is controlled and staff were checking the water wasnt too hot. But they were not recording that they had checked the temperature in the bathroom of a resident who baths independently. The home has looked at the risks of fire and how to control them. There are monthly fire drills and the fire safety system is checked weekly. Though a manager from the company has been visiting the home regularly, she has not been writing a report on her visits every month, as she has to do by law. Staff are receiving feedback from relatives and care managers when they have reviews on each resident. They have not yet had time to carry out surveys of peoples views but the manager said that they are working on a new survey, to make it right for this home. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 23 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 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 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 3 x Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 24 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 YA2 Regulation 14 Requirement The home must obtain a copy of the care managers assessment for each resident before they are admitted. Care plans must always be kept up-to-date. Guidelines for responding to behaviour must include detailed information about what may make each person upset or angry, how staff should try and avoid this happening and how staff should respond if the resident has become upset. If the residents weight needs to be monitored, staff must record each time they are weighed. Care plans must include written guidelines on how medication is given to someone, when special instructions are needed. The manager must check current Health Authority guidelines on training required for staff to give DS0000069669.V351051.R01.S.doc Timescale for action 31/10/07 2 YA6 15 31/10/07 3 YA17 12 31/10/07 4 YA20 13 31/10/07 Trinity House Version 5.2 Page 25 out emergency medication for seizures. 5 YA23 13 The manager must obtain a copy of the local area policy on child protection. The manager must check if noise from the laundry can be heard in the bedroom above. If it is noisy, the laundry must not be used at night. Records must be kept of the training each person receives. All staff must complete training in food hygiene and first aid as soon as possible. The company which runs the home must keep checking that the manager has time for record-keeping and other management tasks. Staff must record regular checks of the temperature of hot water at any taps used by residents. They must record checks of the safety of bedrails and wheelchairs. The boiler cupboard in the dining room must be kept locked. 30/11/07 6 YA24 23 31/10/07 7 YA35 18 30/11/07 8 YA37 10 31/10/07 9 YA42 13 31/10/07 Trinity House DS0000069669.V351051.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 Refer to Standard YA20 Good Practice Recommendations The manager should ask for information about how emergency medication for seizures can be given to be included in the type of care plan used locally. This format of care plan sets out clearly who has been trained to do this and who has consented to the use of this medication. Trinity House DS0000069669.V351051.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Trinity House DS0000069669.V351051.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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