Inspection on 08/12/08 for Wallace Mews

This inspection was carried out on 8th December 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wallace Mews 15/05/07

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Blenheim House

Prince Bishop Court

Park View (15)

Craigmore House

Extracts from inspection reports are licensed from CQC, this page was updated on 20/03/2009.

CARE HOME ADULTS 18-65 Wallace Mews 230 Mowbray Road South Shields Tyne and Wear NE33 3BE Lead Inspector Irene Bowater Key Unannounced Inspection 8th December 2008 13:30a Wallace Mews DS0000067985.V373577.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 Wallace Mews DS0000067985.V373577.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. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wallace Mews Address 230 Mowbray Road South Shields Tyne and Wear NE33 3BE 0191 4541551 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) karen.wallacemews@hotmail.co.uk Minster Pathways Limited Manager post vacant Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (12), Physical disability (12), of places Physical disability over 65 years of age (12) Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2007 Brief Description of the Service: Wallace Mews is a purpose built home intended to provide short-break and rehabilitation places for persons with physical and / or learning disabilities. The home no longer employs registered nurses and therefore cannot provide dedicated nursing care. Should anyone need any nursing intervention this must be supplied by the community nursing services. The home has two storeys’ with level access on both and lift access between the floors. It has been equipped to a good standard with many adaptations especially suited to the people it intends to serve. It is located in a quiet suburban area close to the sea front, and the Lees Nature Reserve at South Shields. It is close to many of the town’s amenities such as the marine park, theatres, restaurants and entertainments, as well as the shopping centre. Fee rates range from £1,123.04 to £1,370.00. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. Before the visit: We looked at: Information we have received since the last visits on 26 July 2007. How the service dealt with any complaints and concerns since the last visit. Any changes to how the home is run. The provider’s view of how well they care for people. The views of people who use the service and their relatives, staff and other professionals. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The Visit: An unannounced visit was made on the 8 December 2008. This visit was made as there have been concerns raised over a three-month period about the management of the home, staffing and safeguarding adult alerts. The visit was carried out by two Inspectors and took four and a half hours to complete. During the visit we: Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 6 Talked with people who use the service, relatives, staff, the manager and visitors. Looked at information about the people who use the service and how well their needs are met. Looked at a sample of other records, which must be kept. Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. Looked around the building to make sure it was clean, safe and comfortable. Checked what improvements had been made since the last visit We told the manager what we found. What the service does well: Staff are respectful and sensitive with people when helping them or when speaking to them. Visitors are always welcomed and there are links with the local community. A programme of activities is available so that people can enjoy social and leisure events. Information about the home, advocacy and events are readily available in the reception entrance. The recruitment procedures are properly followed which help prevent risk to those living in the home by making sure that the right checks are carried out before starting work. The environment has been purposely designed to meet the needs of the people using it. The home is decorated in a modern style and has a range of specialist equipment. People have brought some small items with them making their own bedrooms individualised and homely. The meals are nicely cooked with choices available. Information is available should anyone have a concern or complaint about the care or service they are receiving. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 7 There are good arrangements for supporting people to keep their personal monies in a safe place if they want. What has improved since the last inspection? What they could do better: The preadmission process needs to be comprehensive and completed by care managers and a senior person from the home. The senior staff in the home must have sufficient information to decide whether or not a person can be admitted taking into account the needs of that person and others living in the home. Further work is needed with care planning so that they clearly detail the wishes of people using the service, and the care and support needed to meet people’s needs. People and their representatives need to be involved in planning their own care with staff. Risk assessments detail to guide staff interventions and show how people are being supported and protected. Staff need to follow medication policies at all times so that people receive their medication properly. The security and storage of medication must be reviewed. The training and skills of the staff team need to be reviewed so that the staff are confident they have the skills to do the job. All staff need to have Safeguarding training so that they can recognise any sign of abuse and be confident to raise and alert to the appropriate services. A washing machine that has specific disinfection programmes needs to be provided and the light cords need to be replaced. This will assist in preventing outbreaks of infection. The staff must keep in contact with specialists so that people are given sufficient guidance to enable them develop and maintain personal relationships. This will ensure people make appropriate decisions and friendships, which keep them, safe. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 8 The staff need constant support so that they can feel confident that they will be able to meet people’s needs in a professional manner, taking the principles of a person centred approach to care into account. The Company’s quality assurance system needs to be followed so that people receive consistent quality of care and their views are taken into account. The new manager should progress with her application to become registered with CSCI. 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. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The pr admission assessment information varies in quality. This means that people cannot be sure that their diverse needs are going to be met when they move to the home. EVIDENCE: The preadmission assessments from care managers varied in detail .For example: One was dated the 8 September 2008 and included only a care plan review form rather than a full assessment. A detailed faxed assessment on the 2 June 2008 was about a year old. Another ‘initial assessment’ offered a brief overview of one person’s needs only. Another showed that a detailed care manager’s assessment had been provided before admission and this person made two visits before admission. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 11 The home has an admission checklist which includes likes, dislikes, and risk assessments. Given people’s complex and diverse health and social care needs the admission details were not completed to show how the manager has gained sufficient information to decide whether or not each person’s needs can be met. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. Choice and risk taking are not consistently managed or planned for in a way that would support people in a person centred or safe way. This may impact on people’s long-term health and safety when taking risks. EVIDENCE: Each person has a plan of care, which is based on the information provided by the care manager and the assessment carried out by a representative of the home. The detail in the assessments varies, therefore the plans do not fully show how people’s individual care needs are being met. The plans are not always person centred and do not make reference to individuals needs regarding age, sexual beliefs or education. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 13 Care plan A shows that the person may become aggressive, disruptive, cause harm or self-harm do not have detailed risk management plans in place. No triggers are identified which would show how the types of aggression are being managed. For example (shouting, hitting or self harm). The strategy is to offer time to relax, remove by asking X to remain in the bedroom with no timescales given. Also there were no care plans or risk assessments on sexual health or promoting specific independent living. Care plan B showed that the pen picture was incomplete. Care plans were in place for speech, alcohol use, independence and personal hygiene, Risk assessments were completed for self neglect, limited mobility and finance. However with the risk assessment for limited mobility there is little information about alcohol use, which is a major reason for this person’s falls. Also the guidance given to discourage alcohol is ineffective as the focus is on finances, which the person retains control of. This person has had accidents due to being intoxicated. There is no evidence that any support has been sought from the community services or the care manager. There are no health appointments noted in the relevant sections of the care file, however these are written up within the daily notes. The daily notes evidence a lot of excessive drinking and consequent accidents. Care plan C shows that a detailed assessment was provided but this was about a year old. There is a long complex history with some behaviour that may challenge but there are no care plans or risk assessments in place to show how staff would support this person. There is a care plan about needing a safe environment but nothing about building skills and self worth. Care plan D shows risk assessment for challenging behaviours. Again this does not identify what the behaviours are, what the triggers might be, and any management strategies, monitoring or recording arrangements. There is a risk that this person may run away from the service, but there is no photo on file, and the missing persons procedure offers only limited guidance. The risk assessments are brief about management of the situation. For example what is check on a regular basis, what is regular, how long to leave it before ringing, what to do if there is no reply and which care manager is to be rung. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 14 The plans were not easy to follow and the style based on a nursing model of care, which is difficult for care staff to use. It was possible to see that people’s care plans are being reviewed and daily progress notes record daily events, incidents and social activities. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 15 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): 12,13,15,16,17. Quality in this outcome area is good. Opportunities to take part in meaningful activities and keep control of everyday decisions is good and content and organisation of mealtimes organised. This means people can live active lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is evidence to show that people living in the home are encouraged to maintain and develop their choice of activities and life styles. Although this happens on a daily basis the care plans do not show how this is to happen and who is involved. Some people go to day centres and college; others go out independently whilst some remain in the home. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 16 Photographs are in albums of past events and people said they enjoyed going out regularly and also liked playing on the Wii listening to music, playing bingo watching films and helping around the home. Although people are supported to live an independent lifestyle there is limited understanding and support to make sure the younger people have access to advice and educational guidance about developing personal and sexual relationships either with each other or outside of the home. This has resulted in people being placed in a vulnerable position, which they do not fully understand. There is a new cook and she provides lots of varied food to suit different likes and dislikes. The main meal is served in the evening with a snack or packed lunch. People can choose from having a light meal of cereals and toast to having a full cooked breakfast. The dining rooms have fridges with various snack, milk and juices. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Access to health care is satisfactory, but lack of detailed care planning does not demonstrate that peoples’ needs are being fully met. EVIDENCE: The new manager is in the process of developing a key worker system and a person centred approach to care. Staff are not always aware or sensitive to people’s individual needs and sometimes do not fully understand how to respond to behaviours that may challenge. Examples of this include one person’s alcohol consumption and vulnerability and another’s lack of sexual awareness. The style of the care plans are based on a nursing model and staff are not always completing the health care section. However the daily progress sheets record when health care professionals have visited the home. This includes Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 18 GP’s district nurses and contacting the Speech and Language Therapists should anyone have difficulty with eating or swallowing. Risk assessments in the care plans have not always been updated when people’s health has improved. For example one care plan refers to “needing full assistance” when in fact this person is now walking very well. Risk assessments are not in place for those people who may have seizures. And care plans are not specific about how these episodes are managed by staff. There are medication policies for staff to follow. Staff who administer medication have been trained. The room where medication is kept was full of clutter. Medication was being stored in plastic containers, which although in a locked room were not in a metal cupboard. There is a mixture of systems in use either Monitored dosage or bottles. One person is using the Nomad system. The Medication Administration Records (MAR) showed no gaps and a brief audit of medication was correct. When staff were handwriting directions onto the MAR there were not two signatures to show that the transcriptions were copied properly. Staff was not recording the date of opening of eye drops to make sure they did not become out of date. Also given the location of the room more security should be provided. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 19 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 adequate This judgement has been made using available evidence including a visit to this service. Complaint management is satisfactory but safeguarding issues have not always been well managed and leave people at risk of harm. EVIDENCE: The home have complaints policies and procedures for staff to follow. There has been one anonymous complaint about lack of staff training, senior staff not following recruitment and selection procedures, parts of the home being dirty and the dumb waiter being broken. This was passed to the provided for investigation and a full response given to the Commission. As there were other concerns about the management of the home and three safeguarding alerts a detailed report of events and actions taken by the provider were sent to the Commission. In December 2008 a serious safeguarding allegation was made which the host Local Authority is still investigating. The allegations made and events that followed resulted in the Commission carrying out an unannounced Key Inspection. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 20 Throughout all of the issues the Regional Manager and the new manager have fully cooperated with all of the agencies. Not all staff have had training in dealing with behaviours that challenge and Safeguarding Adults. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 21 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): 24,25,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is a comfortable, pleasant place to live and it is well maintained to encourage people’s independence. EVIDENCE: The home is purpose built over two levels. There is an accessible car park to the rear of the home and all areas are accessible to wheelchair users. A bungalow is being built in the grounds of the home. The Provider hopes to register the service for three people with complex needs. There are lounges and dining rooms on both floors although the upper floor facilities appear to be more popular. All of the communal areas are pleasantly furnished and decorated and reflect the age group of the people living there. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 22 There is some damage to walls and doors from wheelchairs and trolleys. All of the bedrooms are large and have full en suite facilities. Good adaptations including overhead hoists, profiling beds and wet room showers are available. People have also been encouraged to personalise their own space and lots of posters DVD’S and religious artefacts are displayed. All of the bedrooms have different names such as Kirkpatrick, Grotto and Harton to reflect the area. This may cause some confusion for people with limited understanding, as these names are not personalised to them. Previously the bedroom doors had an electronic “swipe” device. This is no longer in use, which makes it difficult for people to access their own rooms independently. The front upper bedrooms have balcony access. Risk assessments for these areas need to be developed and as Christmas lighting was dangling from one balcony the wiring needs to be secured and a separate risk assessment completed. The home was nicely decorated for the Christmas Season. It was clean and tidy with no apparent odours. The light cords in the toilets are grubby and cannot be cleaned on a daily basis, which could be an infection control risk. The laundry is on the lower floor and is domestic in style. There is no hand wash facility in the room and none of the machines has a sluice wash service. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems around staffing levels and recruitment are satisfactory but the training only adequately meets the range of needs of the people using the service. This means that people’s lifestyles are restricted and overall affects their quality of life. EVIDENCE: Since July 2008 the home no longer provides nursing care. This has meant that the care staff had to change their way of working to become trained and qualified to care for the people living in the home. It also meant they were more accountable and responsible for their actions as this previously had been the responsibility of the nursing staff and the registered manager who was also a nurse. The manager left and the home was without a manager for some time. The Provider did advertise and a manager was appointed but left after three weeks. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 24 During this period the Regional Manager has been overseeing the service. A manager was appointed from a sister home and has only been in post for a very short time. Given all of the changes several staff have left and new staff have been employed. Therefore it is a new team who are just starting to work together and understand their roles and responsibilities. Care staff have been promoted and senior staff have completed National Vocational Qualifications (NVQ) level 3. Recruitment procedures are correctly followed to minimise the risks to those living in the home. There was evidence of completed application forms, two written references, Criminal Record Bureau checks and proof of identity. Training records are being developed and those looked at showed staff have completed mandatory training, Safe handling of medication, Health and Safety, Challenging Behaviours, City and Guilds training in Learning Disability, Mental Capacity and effective supervision. Given the client group further training is needed so that everyone’s needs can be met. This includes Safeguarding Adults, assessing rights and risks, Learning Disability Award Framework, including how to provide a person centred approach to care delivery. The new manager has started to complete supervision with the staff team. Records are kept and the aim is to improve the service for those living in the home and develop the individual member of staff. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 25 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): 37,39,42. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Previous inconsistent management means there has been there is a lack of leadership and guidance, which means there is only adequate quality assurance systems in place and people have been placed at risk. EVIDENCE: The home has been without consistent management for some time. The previous manager left earlier in the year and although another manager was employed she only stayed in post for three weeks. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 26 The regional manager is aware of the lack of leadership and direction given in the home over the last six months and has completed a full review of the service provision. Previously staff have been unsure what is expected of them and then doing what they think is right. This means the focus has been the task, getting the job done without looking at the individual needs of those using the service. This has included changing the care provision from nursing to personal and social care. This has meant many changes for the care staff who now have to be in charge of the home and make day-to-day decisions about people’s welfare and safety. Several staff have left and a new staff team is being developed. A new manager has been appointed although has only been in post for a short time. She has National Vocational Qualification level 3 and has started to complete the Registered Managers Award. She is aware of the areas that need to be developed and has a plan of how this is to be done. This includes further staff training especially in caring for people with Learning Disabilities, supervision of staff and developing a person centred approach to care delivery. There is also a need to have more communication and discussion with the care managers about how individual care provision can impact on others in the home and management strategies put in place so that people’s quality of life is not compromised. Staff meetings have been re introduced. Staff have been made aware of their responsibilities, a work schedule has been introduced and formal supervision of all grades of staff has started. People are being supported to manage their money whenever possible and they have access to their records whenever they wish. Staff are aware and concerned about one person’s spending and need to discuss this with them and the care manager. Accidents and incidents are recorded and but best practice guidance is not being used to track trends, which would prevents as far as possible the same things occurring. Mandatory training is now being brought up to date. Internal maintenance checks are up to date and external service certificates are available and up to date. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 27 Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 28 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 2 ENVIRONMENT Standard No Score 24 3 25 3 26 4 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 2 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 2 X 2 X Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 29 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 registered person must ensure that everyone is only admitted be admitted following a full assessment undertaken by a care manager, or other suitably qualified person. This is to ensure that the manager has sufficient information to decide whether or not each person’s needs can be met. Timescale for action 31/01/09 2 YA6 13,15 3 YA7 12 4 YA9 13,15 The registered persons must 01/03/09 ensure that the care plans are up to date; person centred and reflect current and changing needs. This must include how to deal with behaviours that may challenge. The registered persons must 01/03/09 ensure that people are given appropriate information about their rights to make decisions, which are recorded in the care plan and agreed. This is to show how choices are made and why decisions are sometimes made by others. The registered person must 01/02/09 ensure risk assessments contain sufficient information to guide DS0000067985.V373577.R01.S.doc Version 5.2 Page 30 Wallace Mews 5 YA15 16,23 6 YA19 12,13 7 YA20 12,13 8 YA20 13,23 9 YA23 12,13,18 10 YA30 13,23 the practice of care staff. This is to ensure they have sufficient guidance to keep people safe. The registered persons must ensure the people are given sufficient specialist guidance to enable them develop and maintain personal relationships. This will ensure people make appropriate decisions and friendships, which keep them, safe. The registered persons must ensure that risk assessments and care plans are detailed regarding management of epilepsy and alcohol consumption. This is to ensure people’s physical and heath care needs are met. The registered persons must ensure that all handwritten directions on the administration records have two signatures. The date of opening must be written on eye drop medication. This will make sure people receive their medication safely. The registered persons must ensure that all medicines are stored in line with the guidance from the Royal Pharmaceutical Society. All medicines must be stored in a locked cupboard to ensure safety. The registered persons must ensure that all staff receive safeguarding training which links into the Local Authority Framework. Staff also must have further training in dealing with physical and verbal aggression. The will ensure people are protected from abuse, neglect and self-harm. The registered persons must ensure that the light cords are DS0000067985.V373577.R01.S.doc 01/03/09 01/03/09 01/02/09 01/02/09 01/06/09 01/02/09 Wallace Mews Version 5.2 Page 31 11 YA32 18 12 YA35 12,18 13 YA39 24 changed and are able to be cleaned regularly. A washing machine with specified programming facilities to meet disinfection standards must be provided. This will ensure the spread of infection is controlled as far as possible. The registered persons must ensure that all grades of staff have further training to ensure they have the skills and knowledge to support people with complex needs. The registered persons must implement a training and development programme, which includes the Learning Disability Award Framework, Person Centred Care, Bullying and Harassment. This will ensure people’s individual and joint needs are met by a skilled work force. The registered persons must maintain systems of evaluating all aspects of the service and take the views of people using the service and others into account. This will ensure the service provision continues to develop 01/06/09 01/03/09 01/06/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA20 Good Practice Recommendations It is highly recommended that the style of the care plans are reviewed and they are written in a style understood by the person. It is highly recommended that the security of medication DS0000067985.V373577.R01.S.doc Version 5.2 Page 32 Wallace Mews 3 4 5 6 7 YA26 YA36 YA37 YA40 YA42 storage be reviewed. It is highly recommended that the electronic access to bedrooms is re instated. It is highly recommended that the support and supervision of staff continue to be developed. It is highly recommended that the manager progresses with training and application to be come registered with the Commission. It is highly recommended that the home develop a missing people and hospital admissions sheet. It is highly recommended that analysis of accidents and incidents are carried out to track trends so that the same risks are prevented as far as possible. Wallace Mews DS0000067985.V373577.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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