Inspection on 14/08/07 for Wall Street

This inspection was carried out on 14th August 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wall Street 12/11/08

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Briar Hill House

Radbrook Nursing Home

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

CARE HOME ADULTS 18-65 Wall Street Wall Street Hereford Herefordshire HR4 9HP Lead Inspector Debra Lewis Key Unannounced Inspection 14th August 2007 11:00 Wall Street DS0000070241.V349085.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 Wall Street DS0000070241.V349085.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. Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wall Street Address Wall Street Hereford Herefordshire HR4 9HP 01432 342683 01432 340609 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) www.grooms-shaftesbury.org.uk Grooms-Shaftesbury Mr Stephen Macdonald Nicolson Care Home 10 Category(ies) of Physical disability (10) registration, with number of places Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents may also have a mental disorder associated with their physical disability. 4 Residents may have a learning disability associated with their physical disability. 26.2.07 Date of last inspection Brief Description of the Service: Grooms-Shaftesbury is a newly formed national Christian society with charitable status. The service provided at 14 Wall Street is primarily for adults with physical disabilities or acquired head injuries. [The scheme also provides emergency cover for the adjacent independent flats, however these are not subject to registration under the Care Standards Act.] The premises were purpose built in 1993 and are situated in Hereford city centre, giving good access to the local community. The home’s manager, Stephen Nicolson, began working in the home in January 2007 and was registered with CSCI in February 2007. In June 2007 the home’s previous provider, the Shaftesbury Society, merged with another charitable organisation to form Grooms-Shaftesbury. The responsible individual for GroomsShaftesbury is Kim Haldenby. Information about the home is available in the form of a service users’ guide, and the home gives copies of the inspection reports to tenants. The places in the home are block purchased by Herefordshire Council. Items not covered by the fees, which tenants will have to pay extra for, are holidays, entertainments, transport, clothing and social activities / outings. People living in the home are known as tenants (rather than service users) and will be referred to as tenants in this report. Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first inspection of 2007-8. It was a Key Inspection. This means that the inspector checked all of the standards which have most impact on service users. This report includes findings from the visit to the home, as well as any relevant information that has been received about the home since the last inspection. This includes details from a report on the quality of the home, provided by the registered manager. The inspector was in the home from 11 a.m. until early evening. The inspector met and talked with 5 of the tenants, 3 at more length; with several staff on duty; and with the registered manager. Surveys were sent to people living in the home, to their relatives and to professionals involved with supporting people who live in the home, to find out some of their views of the home. 7 tenants, 3 relatives and 4 professionals responded, and their feedback was generally positive. Some has been included in this report. What the service does well: The home checks what care people need before they move to the home, to make sure the home can meet their needs. People have chances to visit the home before moving in, to decide if they like it. The staff have up to date details of the care needed by each tenant, so staff can always provide what is needed. They are also aware of risks to tenants and how to reduce these risks. Tenants make their own choices and decisions in the home and do not feel restricted. They are usually able to get out into the community when they want, and family and friends are made welcome in the home. Tenants choose their food and are helped to make healthy choices if necessary. Tenants feel happy about telling staff if they have any concerns about the home. Staff have good relationships with tenants and have relevant qualifications, helping them to provide good care for tenants. The home makes sure proper checks are done before staff work in the home, to make it less likely that unsuitable staff are employed. The registered manager is making noticeable improvements in the home and makes sure that tenants and staff are included in decision-making and changes. Staff and tenants like him and say he does a good job. Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home should continue to improve staffing levels, to ensure that people who would like to be more active outside the home are able to do so. Staff should take care to keep accurate records of every aspect of medication, to reduce risks to the health of tenants. Further staff training is needed to make sure everyone is up to date with basic training, in order to consistently provide the best care for tenants. Grooms-Shaftesbury need to do full checks at least once a year on the quality of the service given at Wall Street, and make plans for improvements there. The home must make sure that all risks in the home are considered, and action is taken to reduce them. This must be recorded and regularly updated, to help keep the home safe for tenants. Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 7 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. Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is enough information available for prospective tenants, although this should always be given in written form as well as verbally. The home ensures it is fully aware of, and can meet, people’s needs before agreeing admissions. EVIDENCE: An updated statement of purpose / service users’ guide was provided, which now included the information which had been missing. It was available in different formats if needed. From the survey and from talking with tenants it appeared that this had not always been provided before they moved in, although they mostly felt they had enough information about the home to make their choice. The home should make sure this is always available in writing so prospective tenants have time to read and digest the information. The home obtained full assessments of people’s needs before they agreed to admit them, and the registered manager had been proactive in ensuring these assessments were up to date and covered all needs, in one instance arranging for an occupational therapy assessment which resulted in improved range of aids being provided to one new tenant. Existing tenants are consulted about possible new tenants. Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 10 Wall Street DS0000070241.V349085.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, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is aware of, and records, tenants’ needs. Staff are also aware of risks to tenants but work with tenants to ensure that they can lead as full lives as they are able to. Tenants feel in control of their daily lives and choices. EVIDENCE: The inspector saw samples of service user plans and risk assessments. These were detailed and up to date, and had been reviewed recently. All needs were assessed and any concerns were linked to corresponding risk assessments, needs were linked to service user plans. Service user plans were written in the first person, making them feel more “owned” by the tenant, and contained full details of the care needed by individuals. The registered manager said agency staff had commented on the new style plans, finding them helpful and informative. Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 12 7 tenants responded to the survey. Of these, all said they could do what they wanted. Comments included “There have never been any restrictions on what I want to do”. Most said they always (one said usually, one said sometimes) decided what they did each day. [See also next section, Lifestyle] Wall Street DS0000070241.V349085.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, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Tenants are able to take part in varying activities according to their interests and abilities, and there are normally sufficient staff to enable this to take place. They are part of the Hereford community, using local facilities. Family, friendships and relationships are welcomed. Food is prepared individually according to tenants’ needs and preferences. EVIDENCE: The registered manager gave the following information: “Tenants are offered access to day centres, colleges (Holme Lacy, Growing point), social clubs, local amenities (such as libraries, job centre, parks, shops, cafes, public houses, theatre, football club, etc.), local public and private transport, dependant upon the individual tenants interests and capabilities. Family and friends may visit at anytime, and sign in through the main entrance and may go out with tenants, or have privacy on site as required. Daily activities involve some routine but are flexible and requests are Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 14 scheduled in whenever possible, with healthcare appointments taking preference as required. Tenants choose their own professional support, for example the site accesses six surgeries for the various tenants. Tenants who wish to access the community on their own are able to do so as they wish, and let staff know if they are leaving the site. Staff are regularly reminded about privacy, confidentiality and dignity for tenants, and are asked to knock on tenants doors before entering the room. All tenants have individual choice for all meals, which are prepared individually, unless they wish to join Sunday lunch, brunch club, options as they are available. Tenants can choose to get food from a range of local suppliers. Tenants are encouraged to to choose what they wish, and wherever possible to shop individually for items with appropriate levels of assistance. Tenants are undergoing a series of medical reviews, and the advice of a dietician will be sought if required. Dietary advice has been given and is being followed for a resident suffering from diabetes, and regular advice is given to tenants through meetings, help with shopping and lists, etc.” This information was confirmed during the inspection, from observation and discussion with tenants and staff. For example one tenant is accompanied in a supermarket by the store’s “personal shopper”. Comments from the survey of tenants included “I have lie-ins when I want, get up when I want, watch TV of my choice” “I go out whenever I want to and when staff is available.” “I am able to come & go as I please, as long as staff are told I am leaving.” “I have plans of my own. I have plans ahead for holidays, family visits.” “I choose what I eat within limits of my diabetes.” In the past the home has had more support from volunteers, which was withdrawn and has been sorely missed by tenants whose lifestyle had been restricted as a result. The home has also had what seems to be a low level of funding compared to a high level of support needed by tenants. This situation has been an issue for several years and the registered manager continues to negotiate for more suitable funding arrangements. Tenants have this year mainly felt better able to do what they wanted, as the home has been almost fully staffed and there have been vacancies. However some tenants commented that they felt low staffing levels sometimes restricted what they could do, for example “I would like to do more during the day but it is not always possible due to shortage of staff; I am not always able to do things during the evening as staff are not always available; there is a shortage of staff so I am not able to go out as much as I would.”[all same person]. “Staffing levels sometimes restrict my decisions on certain activities.” One tenant said the home was “a bit boring sometimes”. One person commented “I sometimes go out with staff if enough staff are here… I would like to be able to go out more in the evenings, to the pub etc., but this is not always possible Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 15 due to staffing levels.” A professional who responded to the survey commented that “They often have limited resources to be able to go out with clients to access opportunities…… They have however tried to find alternative support networks for clients.” This was discussed with the registered manager, who felt the home was currently able to offer a high level of support with activities. The inspector saw records showing tenants’ visits out of the home during the past 2 weeks, which showed a range of about 3-6 visits out of the home during the week for tenants needing to be accompanied by staff. Further discussions with the registered manager, tenants and staff suggested that there had been a difficult period in the recent past with staff sickness, which had now passed so activities were now more freely possible. The registered manager has improved the situation considerably this year by putting effort and attention into the staffing levels and also addressing the funding arrangements and the level of care needed by potential tenants. He must continue to keep a close eye on staff availability to ensure tenants’ lifestyles are not restricted in the future. It is also possible that some tenants still wish for more freedom to come and go especially during the evenings, as is possible for most able-bodied people, for example many younger people who are often out a lot. This needs to be continually addressed, particularly when funding negotiations are taking place. Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home makes sure that tenants’ personal care and health care is given as required by the home and by local health professionals where necessary. Medication is mostly well managed, but the home staff sometimes need to keep more accurate records, to ensure the safety of tenants. EVIDENCE: Service user plans included up to date details of personal care and healthcare needed by each person. They included detailed of records of care provided by health professionals, e.g. appointments with and treatment by GPs, nurses, and consultants. The home liaised with such professionals to ensure tenants’ (sometimes complex) medical needs were reviewed and provided for. There were few male staff, limiting choice for provision of personal care, but the home had records of tenants’ preferences for male or female carers and usually choice was possible. The registered manager had introduced “Quick reference guides” for each tenant, with a summary of their needs, current medication, next of kin, professional and family contacts etc. These had been used to accompany a Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 17 tenant who had been admitted as an emergency to hospital, and ward staff had commented how useful it was to have easily accessible information in these circumstances. A previous inspection by a pharmacy inspector had identified a range of improvements needed in the way medication was handled in the home. Most aspects had been addressed, including staff training and the need for a protocol for giving “as required” medications, but the inspector found some areas still needing attention: • • • • When a variable dose was prescribed, staff had not always recorded what dose was actually given. This is important for the safety of tenants, to know exactly what dose they have had. If a dose was missed staff had not always recorded why. Records for a skin patch to be applied every 3 days showed a shorter time gap, without a record of why this was. MAR charts (medication administration records) showed a medication was being given every 2 days as stated by the GP, but the chart said it was “as required”. The home needs to ensure that instructions on the medication packs and MAR charts are accurate and agree with GP instructions, to avoid staff confusion and ensure the correct dose is given. The home’s policy still needs reviewing; this is imminent following the Shaftesbury merger with Grooms. • Tenants were supported where possible with self-medication and this was confirmed by external professionals associated with the care of tenants. Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has suitable policies for responding to complaints and for safeguarding tenants. Most staff have had the training they need. Tenants know how to raise concerns and are happy to do so; the home has a positive, open approach to listening to concerns. EVIDENCE: The home had a suitable complaint policy. All tenants who responded to the survey, or who spoke with the inspector, said they knew what to do if they had a concern and were aware of the complaints procedure. Records showed the registered manager had increased the recording of concerns and complaints, including details of staff concerns as well as tenants’ concerns, and of any action / outcome to the concerns. This ensures tenants’ concerns are taken seriously. Relatives were satisfied with the complaints procedure and professional felt concerns were usually dealt with appropriately. Approximately two thirds of the staff had done training in adult protection and the home had a suitable policy in place, meaning that should any tenant need safeguarding from possible abuse then the home staff should know what to do and take the right action. Further training is being arranged for staff who have not yet had it. Wall Street DS0000070241.V349085.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): 24, 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is well maintained and is clean, accessible and comfortable. Staff and tenants contribute to improving its décor. Staff training is being updated to ensure they maintain hygiene in the home. EVIDENCE: The home had been redecorated (corridors and lounge) according to tenants’ tastes, with more pictures hung on walls. Some carpets were still in need of replacement, this was being planned. The outside courtyard had been tidied and improved, making it a pleasant outdoors area with a water feature, flowers and a gazebo for smokers to shelter under. Tenants said the home is always or mostly fresh and clean; it was on the day of the inspection. Many staff have now been trained in food hygiene and infection control, and further training is being arranged for those who have not yet had it. Wall Street DS0000070241.V349085.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, 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are usually enough staff in the home, and tenants like them. Staff are suitably qualified, but need more regular training, which is being arranged. The home follows safe recruitment procedures, to reduce the risk of employing unsuitable staff. EVIDENCE: Rotas showed the manager’s hours and demonstrated that there were almost always 3 staff on duty. This is normally sufficient, but the home needs to be continually aware of the wishes of any tenants who may prefer to be more active, which may require higher staffing levels at times. Staff were now receiving suitable training. While this was not yet up to date, a lot had been achieved in the past year and the registered manager was committed to ensuring staff had the training they needed to provide the best possible care. More than half of the care staff held a NVQ in care and more were undertaking this qualification. This should help further improve the care given to tenants. Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 21 13 staff were due to do Disability Awareness training in August, which should be beneficial for tenants as hopefully it will increase staff understanding of important issues for people who are disabled. Staff recruitment records were sampled and showed that appropriate procedures were being followed, including a written application form, interview, written references, proof of identity, full employment history and a satisfactory CRB (Criminal Records Bureau) disclosure before working in the home. This applied to agency staff as well as permanent staff. This reduces the risk of unsuitable staff working with tenants. Tenants’ comments about staff included “Even with what I believe is poor staffing level, I feel that my care needs are met and I have a reasonable quality of life under the circumstances.” “I am very happy at this home and I am treated well.” “Very helpful.” “Sometimes when I’m upset I don’t always think staff are right. But it is all right after.” “If I have problems staff always help.” All 7 who responded to the survey said staff always listened and acted on what they said. Wall Street DS0000070241.V349085.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, 40 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is suitably trained, qualified and experienced, and tenants and staff like him. He has made many improvements in the home. The home does not yet have an established system of checking the overall quality of the service provided to tenants. The home is mostly kept safe for tenants but further safeguards are still needed. EVIDENCE: The registered manager began working in the home in January 2007 and was registered with CSCI in February 2007. He has a City and Guilds NVQ level 4 in care and the registered managers’ award, both achieved in 2006 and has previously been the registered manager of another home. Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 23 Since registration with CSCI (Commission for Social Care Inspection) the registered manager has been in touch with CSCI to share relevant information and update us on his planned changes. He has continued to implement changes in the home and improve systems. The home had been without a registered manager for a considerable period so he had inherited a backlog of work. Progress was evident. Staff and tenants were positive about him – comments included “Very nice” “A good genuine guy; he can be relied on” and “Very good; he’s taken me shopping, and out for a pint”. Quality assurance is still not fully established, of late due to the merger between Shaftesbury and Grooms. The new organisation needs to agree and implement their own process as soon as possible. In the home, the registered manager had set up daily, weekly and monthly checklists (including noting feedback from tenants) and tenants’ monthly meetings. The registered manager fully and promptly completed the AQAA (Annual Quality Assurance Assessment ) required by CSCI, which included improvement plans for the home, and is aware of the need for a full, quality assurance system to be put in place. General maintenance needed to ensure the safety of the home for tenants (e.g. gas / electrical services / checks) was being done. Some risk assessments were up to date; others were not present (e.g. food hygiene, infection control) or out of date (e.g. fire). Work was in progress but more was needed and this should be prioritised. Individual risk assessments were now in place with no obvious omissions. Fire checks and tests were now all up to date. Staff training was now taking place regularly after staff meetings; fire drills were being carried out monthly to ensure all staff attend one at least annually as is required. Wall Street DS0000070241.V349085.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 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 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 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X X 2 Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes Please note that previous requirements have been revised in order to focus on those breaches of regulations that are most likely to lead to enforcement action. 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 YA35 Regulation 18 Requirement All care staff must receive adequate training needed for their work, including food hygiene, infection control, disability awareness and adult protection. (Timescales of 31.12.06 and 31/05/07 not met, but progress being made) 2 YA42 13 Risk assessments must be in place covering all safe working practice topics as specified in NMS (national minimum standard) 42. These must be regularly reviewed and updated. (Timescales of 30/11/06 and 31/03/07 not met) 31/10/07 Timescale for action 31/03/08 Wall Street DS0000070241.V349085.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 YA14 Good Practice Recommendations The home should keep staffing levels under review, to ensure that tenants are able to take part in activities outside the home as they wish. (Previously a requirement) 2 3 YA16 YA19 Staff should ensure that even during busy periods, they wait for tenants’ permission before entering bedrooms. The home should have a policy on prevention, assessment, monitoring and treatment of pressure areas. (Repeated from February 2007, not checked on this inspection) 4 YA20 The registered provider should quickly arrange for a review and update of the medicine policy and procedures so as to provide all staff with precise direction about the way medicines are managed and handled in this home. (Previously a requirement) 5 YA20 The registered manager should ensure that all deficiencies in medication recording are addressed. (Previously a requirement, most improvements made) 6 YA21 It is recommended that training in respect of death and dying is included in the staff training programme. (Repeated from June 2005, August 2006 and February 2007, not checked on this inspection) 7 YA34 The home should consider involving tenants more directly in recruitment of staff, e.g. via training. (Repeated from August 2006 and February 2007, not checked on this inspection) Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 27 8 YA39 The registered provider should agree and implement their internal quality assurance process without delay. (Previously a requirement) Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Worcester Local Office The Coach House John Comyn Drive Perdiswell Park Droitwich Road WR3 7NW 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 Wall Street DS0000070241.V349085.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!