Inspection on 05/09/07 for Wells Road Care Home

This inspection was carried out on 5th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wells Road Care Home 15/02/09

Wells Road Care Home 19/03/08

Wells Road Care Home 11/04/07

Wells Road Care Home 20/04/06

Wells Road Care Home 15/02/06

Wells Road Care Home 21/03/05

Wells Road Care Home 29/03/04

Wells Road Care Home 10/11/03

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Wells Road Care Home 280-282 Wells Road St Anns Nottingham NG3 3AA Lead Inspector Michael Williams Key Unannounced Inspection 5th September 2007 10:00 Wells Road Care Home DS0000002259.V350622.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 Wells Road Care Home DS0000002259.V350622.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. Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wells Road Care Home Address 280-282 Wells Road St Anns Nottingham NG3 3AA 0115 844 3732 0115 950 2066 mvickis@ncha.org.uk 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) Nottingham Community Housing Association Carmel Hopkinson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users shall be within category LD Date of last inspection 11th April 2007 Brief Description of the Service: Wells Road Care Home is situated in the residential area of St Ann’s, close to shops and amenities and is registered to provide accommodation and support for up to six adults with a learning disability. The home itself is comprised of a pair of semi-detached houses joined together and the accommodation consists of communal lounge, dining room and kitchen on the ground floor and six single bedrooms with shared bathing facilities on the upper floor. There is currently one vacancy. The home has enclosed front and rear gardens accessible to service users. The registered provider is Nottingham Community Housing Association. The current fees are £342 per week; this does not include personal purchase, clothing, magazines and hairdressing. This information is included in the Statement of Purpose, which is made available to prospective service users along with other relevant information about the service upon request. Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspection visit undertaken by the Commission for Social Care Inspection is upon outcomes for service users, and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice, and focuses on aspects of service provision that require further development. This was an unannounced undertaken by one inspector over 6 hours. The main method of inspection used is called ‘case tracking’ which involved selecting two service users and tracking the care they receive through checking their records and discussion with them, and observations of the care received and asking staff about their needs. Records of complaints, staff training, quality assurance, and Health and Safety records were also looked at. Two members of staff were spoken with as part of the inspection. The views of service users who were not part of the ‘case tracking’ were sought to form an opinion about the quality of care provided. A partial tour of the premises was undertaken and a sample of bedrooms seen to ensure that the environment was homely and safe. We were unable to communicate with some service users therefore some judgements in this report are from the observations of staff and resident interactions. A pre inspection questionnaire or annual quality assurance assessment was not available before the inspection. A review of all the information about the home received by the Commission since the last inspection was taken into consideration in planning this inspection and helped in deciding what areas of care were looked at. What the service does well: Pre-admission assessments are undertaken to ensure that the identified needs of service users are addressed. Risk assessments are detailed, thorough, and used to inform the development support plans. Support plans provide information about how service users individual needs are to be supported. Staff are knowledgeable about the needs of people living at the home, interaction between staff and service users is positive and meaningful, and service users are treated with respect and dignity. Family contact is encouraged and supported, and intimate relationships are safely maintained. Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Information about the services offered by the home should be made available in a format appropriate to the needs of service users. Service users or their representatives should sign agreements and contracts. Written confirmation that the home can meet the assessed needs should be provided to service users. To prevent abuse written consent should be obtained from service users or their representatives where restrictions are in place. Where staff are unable to successfully communicate with service users and ascertain their views, and do not have a family representative, independent representation should be sought. To promote independence procedures to identify service users capacity to administer their own medication should be considered. Community resource and links with external organisations should be explored, to promote personal development and provide opportunities for service users to participate in community life. To maintain service users safety a risk assessment of the unguarded radiators in the home should be undertaken, and the risk assessment relating to a service user using the staircase should be reviewed. To ensure the home is being conducted appropriately, and is a safe place for service users to live. The fire risk assessment should be signed and dated by the responsible person. To prevent cross infection, supplies of soap must be maintained in dispensers in toilets and bathrooms Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 7 Accidents should be recorded in line with environmental health inspector recommendations. To ensure that service users are protected, staff recruitment records should be made available for inspection. 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. Wells Road Care Home DS0000002259.V350622.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 Wells Road Care Home DS0000002259.V350622.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 and 4 Quality in this outcome area is good Prospective service users needs are assessed and they are supplied with sufficient information, which enables them to make an informed choice about the service before moving in. However service users are not supplied with contracts, which indicate the provision of services and facilities, which would hold the service accountable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a copy of the home statement of purpose available, which provides information about the aims of the home, facilities, services offered, admission criteria, and information about whom the home may not be suitable for. There is also a service user guides that includes information about the complaints procedure and house rules, copies of the service user guide were viewed in service user rooms. Trial visits and overnight stays are offered; this was confirmed with a service user spoken with. Information about the home is made available upon request. However this Information is not available in a format appropriate for the needs of people living at the home. Files examine contained full community care assessment of individual needs, through discussions with staff it was evident that the home can meet the assessed needs of people living at the home, however there was no written confirmation that the home can meet the assessed needs of service users. Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 10 The terms and conditions of the placement were available; although some agreements viewed were not signed by service users or their representatives. Wells Road Care Home DS0000002259.V350622.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, 8 and 9 Quality in this outcome area is adequate Support plans reflect assessed needs; service users are supported to lead independent lives. The lack of consent to restrictive practices potentially infringes upon service users service users rights to privacy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Files examined contained pre admission assessments on holistic needs such as physical and emotional needs of service users. Information was available about how needs such as sexuality and disability are supported. Support plans are developed from pre admission assessments and risk assessments, and cover wide aspects of physical, emotional and behavioural support needs. Appropriate risk assessments are in place, and information is available to identify when restrictions are in place, for example where poor road safety skills place service users at risk when in the community unsupervised. Risk assessments and support plans are in place for service users who wish to smoke, and for assisting those who need support in opening and reading their mail. Staff spoken with demonstrated a good level of understanding of how to Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 12 communicate with people living at the home using formats such as pictures and easy read. There was evidence that support plans are regularly reviewed and that service users participate in the reviewing process. During the inspection one service user was observed attending his review with a representative, however, there was no written consent to support plans. Documentation examined and observations made during the inspection evidenced that staff provide service users with the information, communication and support to make informed decisions about their lives. Signs, symbols and pictures are used to support those with difficulties with communication and understanding. Service users spoken with said that they are consulted about how the home is run. There are regular service users meetings with minutes available in a format suitable for the needs of people living in the home, The advocacy services, which previously visited the home, have been withdrawn. This has the potential for the abuse of service users who do not have independent representation. For example where a baby monitor is being used in a service users room to monitor their breathing at night, no consent to this practice is in place. This potentially infringes upon service user rights to privacy. There is a risk assessment in place for managing the potential risk of a service user using the staircase. However the risk assessment highlights that there remains a potential risk with the service user using the staircase Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16, and 17 Quality in this outcome area is good Service users are treated with respect and dignity, family and personal relationships are supported. Opportunities are offered for service users to participate in appropriate peer activities and community life. Varied and healthy diets are offered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Files examined contained information about service user interest, likes and dislikes. Some service users attend day centres. Staff spoken with said that the day centre has been contacted regarding arranging flexible day centre package to meet the needs and preference of service users who have chosen not to access full time packages. Examination of individual social activity chart for recording when service users have participated in activities showed little recent community involvement for the service users case tracked. Staff spoken with said that service users are encouraged to participate in activities such as arts and craft, rug making and Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 14 gardening. During the inspection one service users went out into the town centre with staff. Other service users in the home were observed watching T.V, and interacting with staff. Service users spoken with said that there are opportunities to go out to local shops, pubs, and libraries. Support plans make reference to respecting individual rights; during discussions with staff it was clear that they are aware of the importance maintaining service users privacy and dignity. Interaction observed between staff and service users was positive and meaningful. Appropriate support plans are in place for opening mail with service users, and for the use of a monitor in the room of one resident who experiences breathing difficulties. It was also evident that intimate and sexual relationships are supported and safely maintained. “ My boyfriend comes to visit me here”. Family contact is promoted and supported. One service user told us that they were going on holiday with their family “I ‘m going on holiday to Norfolk”. Service users spoken with said that they enjoyed meals offered,” I like the food, spare ribs are my favourite”. During the week service users choose menus on a daily basis. Weekend meals are pre planned by service users, and displayed on the communication board in the kitchen. Signs, symbols and pictures are used to enable service users with communication difficulties to choose menus. Records of daily meals indicated that varied and nutritious meals are offered. Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good Identified health needs are generally met; personal support and health care is provided in a way that service users prefer. Medication policy and procedures protect service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Support plans contain detailed information about the physical and emotional health needs of service users including behaviour, hygiene, and how staff are to support service users and ensure that health needs are maintained. However, from discussions with staff there was a lack of awareness in meeting the assessed needs of one service user case tracked who had been assessed as having an attachment disorder. The support plan contained information about the importance of developing positive relationships and avoiding confrontation with people with attachment disorder, however, there was little information about displayed behaviour, and the importance of maintaining routines and structure. Files viewed evidenced that health professionals such as doctors, psychologists, dentist, and opticians are involved in the care of service users. A new system has been implemented to ensure that service users weight is regularly monitored. Staff spoken with said that the doctor is informed if there are any health issues, this was confirmed with service users spoken with. Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 16 Some service users have refused to attend health appointments; there was evidence that alternative options have been explored to address this. The home is also developing a health information pack focussed at increasing service users understanding of their health needs, and why they need to undertake health checks. There is a copy of Nottingham Community Housing Association medication policy in located in the main office, which contains policy and procedures for the management of medication. There is also an in house medication policy that is being updated, however, there were no procedures in place to assess service users ability to self medicate. The home is registered with local pharmacy who have recently inspected medication management in the home. A copy of the procedures for drug errors are now located inside the medication cabinet, and is easily accessible for staff in the event of an emergency. A record of medication brought into the home is now maintained, and a new system is in place for ensuring that medication is ordered in sufficient time before supplies become depleted. Examination of the Medication administration records evidenced that appropriate procedures are undertaken in administering medication. Staff spoken with said that they had received medication training; this was evidenced in staff files viewed. Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good Service users feel listened to, appropriate policy and procedures are in place to protect service users from abuse and harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of Nottinghamshire adult protection procedures is located in the main office. Copies of the complaints procedure with appropriate timescales for responses and action is available in the statement of purpose and the service user guide. There is also a copy of the complaints procedure in a format suitable for the needs of people living at the home located on the message board in the dinning room. Since the last inspection the Commission has received no complaints, no complaints have been made to the home. Service users spoken with said that she felt safe living at the home, and would speak to staff if they were not happy. Since the last inspection there have been no incidents of restraints or adult protection referrals. Staff spoken with were aware of their responsibilities regarding the protection of vulnerable adults, and the whistle blowing policy. Staff files viewed evidenced staff have received relevant training in adult protection. Examination of financial records evidenced that appropriate procedures are in place to ensure that service users are protected from financial abuse. Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, and 30 Quality in this outcome area is adequate Service users live in a generally clean, hygienic and homely environment. Some safety management procedures and practices may place service users safety at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is generally clean and tidy, with photographs and pictures displayed around the building, creating a homely feel for people living in the home. New carpets have been recently laid and in the lounge and the floors are free from trip hazards. The kitchen is clean, tidy, and hygienic, a new chopping board has been purchased and units are in good condition. Food was stored safely and records for food safety management are effectively maintained. Laundry facilities are adequate for the needs of service users; there are no sluicing facilities. The manager reported that there is no incontinence at the Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 19 home. Any laundry requiring sluicing will be undertaking by an external laundry company. Sufficient supplies of protective gloves are available to prevent cross infection. Bathrooms and toilets were clean however there was no soap in the hand dispenser. Staff spoken with said that this was due service users wasting soap in dispensers, personal toiletries are provided which service users use when they visit the bathroom. However during the inspection service users were observed entering the bathroom with no soap, to use the toilet. The gardens to the front and rear of the property are well maintained. Service users and staff undertake weekly maintenance checks; any repairs required are reported to Nottingham Community Housing Association maintenance department. Since the last inspection the environmental health officer has inspected the premises and recommendations were made to comply with The Health and Safety at Work Act 1974. An action plan has been produced by the home and some improvement in health and safety has been made. Appropriate procedures are in place the control of legionella; Support plans are now in place for the storage of alcohol, beds in service user rooms have been moved away from radiators. Radiators around the home are unguarded, and there is no risk assessment in place to ensure that service users are not at risk from high surface temperatures. This issue is outstanding from the last Key inspection, which required compliance by 11/07/07 and must be addressed to avoid enforcement action from the Commission. Evidence was viewed that request have been made to Nottingham Community Housing Association maintenance department for gas safety and portable appliance testing to be completed. There were no dates available for when the testing will be completed. Wells Road Care Home DS0000002259.V350622.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): 32,34,35 Quality in this outcome area is adequate Sufficient levels of staff support service users. Additional training is required to ensure that staff are able to meet all assessed needs of service users. Recruitment procedures do not ensure that service users are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff spoken with reported that communication amongst the staff team has improved, for various reasons a number of staff are off work at present which has lead to a high number of agency staff are being used. The manager reported that there has been a recent recruitment drive that should address the staffing issue. The rota shows that there is sufficient staff on duty to meet the needs of people living in the home, in addition to this the manager supports care staff with their duties during the more busy periods of the day. Recent changes have been made to the staffing rota, the manager said that this is focussed upon enabling staff to be utilised more creatively, and increase the opportunities for service users to be supported in participating in community activities. Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 21 Staff files examined contained evidence that training had been provided in infection control, Protection from abuse, food hygiene, communication, first aid, managing challenging behaviour, and medication. Training files showed that 50 of the staff team have completed the NVQ level 2 in social care. However there was no evidence that staff had received training in ‘attachment disorder’, highlighted in the assessed needs of one service user case tracked. Staff spoken with confirmed that they had not received training in this area. Staff spoken with were clear about their roles and responsibilities in protecting vulnerable adults. Staff reported that they feel supported by the management, and received regular supervision. This was evidence in staff files examined. Staff recruitment information is held centrally at Nottingham Community Housing Association. There were no records available of the date or reference details of criminal record bureaux (CRB) checks available as agreed with the Commission. Wells Road Care Home DS0000002259.V350622.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, 39,42 Quality in this outcome area is Poor Improvements have been made, however, the management of safety requirements in the home places service users safety at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager leads by example, and adopts an open and supportive management style that she feels is suited to service users and staff team. Since the last inspection improvements have been made, a visitor’s book is now in place. The environmental health officer has inspected the premises, and an action plan has been produced to address health and safety recommendations. Policy and procedures are in place for the control of legionella, and support plans are now in place for the storage of alcohol. Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 23 Adequate supplies of hygienic gloves were available; a new chopping board has been purchased in the kitchen. Food is stored safely in cupboards; records of fridge and freezer temperatures are effectively maintained. Beds in bedrooms viewed are placed away from radiators however, radiators around the home are still unguarded and there is no risk assessment in place to ensure that service users are not at risk from the surface temperatures of radiators. Health and safety documentation showed that the responsible person has not signed the fire risk assessment. Nottingham Community Housing Association maintenance department is in receipt of request for gas safety and portable appliance tests to be completed. However no dates for the completion were available. Accidents reports are not recorded in the format recommended by the environmental health officer. A quality assurance system is in placed, and there are regular visits are undertaken by the provider to assess quality of service. Annual service user questionnaires are completed, and the findings are fed back to service users in service users meetings and used to develop the home’s business strategy for the following year. There were no records available of the date or reference details of criminal record bureaux (CRB) checks available as agreed with the Commission. Wells Road Care Home DS0000002259.V350622.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 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 1 X 3 X X 1 X Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 25 Yes 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 YA5 Regulation 5:1 Requirement To ensure that the home is accountable to service users a contract of the terms and conditions of the placement must be provided. Agreement to contracts must be obtained from service user or their representatives. Written confirmation that the home can meet the assessed needs must be provided to service users. To prevent potential abuse, and involve and empower service users in their chosen lifestyle, where practicable, consent to care plans must be obtained from service users or their representatives. To minimise potential abuse, where restrictions are in place written consent must be obtained from service users or their representatives. To maintain service users safety a risk assessment of the unguarded radiators in the home must be undertaken. This an outstanding requirement from the previous inspection DS0000002259.V350622.R01.S.doc Timescale for action 18/10/07 2. YA3 14:1 (d ) 18/10/07 3. YA6 15 18/10/07 4. YA6 15 18/10/07 5. YA24 13:4 (a) 18/10/07 Wells Road Care Home Version 5.2 Page 26 timescale 11/07/07 6. YA24 13:4 To maintain safety the risk assessment relating to a service user using the staircase must be reviewed. To ensure that the assessed needs of service users are met staff must be booked on training course for ‘attachment disorder’ To ensure that recruitment procedures protect service users staff files must contain documentation relating to the date and reference details of criminal record bureaux (CRB) checks. To ensure the home is being conducted appropriately, and is a safe place for service users to live. The fire risk assessment should be signed and dated by the responsible person. The overdue gas safety and portable appliance testing must be completed to ensure the safety of service users. 18/11/07 7. YA35 18 (c)(i) 18/11/07 8. YA41 19 schedule 2 18/10/07 9. YA41 17 18/10/07 10 YA42 23 18/10/07 Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 27 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 YA1 Good Practice Recommendations Information about this services offered by the home should be made available in formats appropriate to the needs of service users. Where service users do not have relatives, and have difficulties in their understanding, advocacy or independent representation should be sought. Community resource and links with external organisations should be explored, to promote personal development and provide opportunities for service users to participate in community life. To promote independence procedures to identify service users capacity to administer their own medication should be considered. To prevent cross infection, supplies of soap must be maintained in dispensers in toilets and bathrooms Accidents should be recorded in line with environmental health inspector recommendations. 2. 3. YA7 YA11 4. 5. 6. YA19 YA30 YA41 Wells Road Care Home DS0000002259.V350622.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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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