Inspection on 09/05/07 for West Street, 36

This inspection was carried out on 9th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

West Street, 36 08/06/06

West Street, 36 12/01/06

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 West Street, 36 36 West Street Wombwell Barnsley S73 8LA Lead Inspector Mrs Sue Stephens Key Unannounced Inspection 9 May 2007 10:10 DS0000065298.V332043.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 DS0000065298.V332043.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. DS0000065298.V332043.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service West Street, 36 Address 36 West Street Wombwell Barnsley S73 8LA 01226 757269 01226 759573 None www.milburycare.com Milbury Care Services 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) Mrs Karen Armitage Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places DS0000065298.V332043.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One service user as identified on the variation application dated 14.9.05 (who is over the age of 65 years) may be accommodated at the home. One specific service user over the age of 65, named on variation dated 8th December 2006 (V37181), may reside at the home. 8th June 2006 Date of last inspection Brief Description of the Service: 36 West Street is also called Wellham House. Because people who live there called the home Wellham house the home will be referred to as Wellham House in this report. Wellham House is a new purpose built home set in its own grounds. It provides care and accommodation for people with learning disabilities. The lay out and equipment at the home is suitable for people with physical disabilities. There is a passenger lift providing access to both levels. On the ground floor there is a lounge, activities room, dining area and purpose built kitchen. The four bedrooms have direct access to a bathroom or shower area. On the first level floor there are two self-contained flats. The bedrooms and shared spaces exceed the National Minimum Standards for room sizes. There are good amenities, for example shops, pubs, a church and leisure facilities close to the home. Wombwell shopping centre is a short walk from the home and there is public transport into Barnsley town. The manager provided the information about the homes fees and charges on 09 May 2007. Fees range from £1575 to £1675 per week. Additional charges include hairdressing, toiletries, flowers, newspapers and magazines. There is a supplement charge for incontinence pants. Prospective residents and their families can get information about Wellham House by contacting the manager. The home will also provide a copy of the statement of purpose and the latest inspection report. DS0000065298.V332043.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced; it took place between 10:10 am and 17:00pm. The inspector sought the views of two people who live at the home, and spent time observing other people who received support from staff. She interviewed one member of staff. Karen Armitage, the registered manager assisted in the inspection and visit. During the visit the inspector looked at the environment, and made observations on the staffs’ manner and attitude towards people. She checked samples of documents that related to peoples’ care and safety. These included three assessments and care plans, medication records, and three staff recruitment files. The inspector looked at other information before visiting the home, this included evidence from the last random inspection and surveys. The manager said she had not received a pre inspection questionnaire from the Commission for Social Care Inspection (CSCI) for this inspection, however the manager did provide the necessary information to the inspector on the day of the visit. The inspector received views from the following surveys: Four surveys for people who live at the home Three professional visitor surveys Three staff surveys. The random inspection visit took place on 24 November 2006; where the inspector found that the home had made good improvements towards meeting National Minimum Standards. This was a key inspection and the inspector checked all the key standards. The inspector would like to thank the people who live at the home, the manager and staff for their welcome, help and contribution to this inspection. DS0000065298.V332043.R01.S.doc Version 5.2 Page 6 What the service does well: People said they were satisfied with their support and the environment at Wellham House. They used expressions to describe the home, such as, “Happy”, “safe” and “I like it” A relative said they were satisfied and said the staff and manager were very good. People have assessments so that the home understands their needs. And they have support plans with information that helps staff to support them. People are involved in their assessments, plans and reviews. This helps people to be in control of their own support needs. The assessments and support plans consider peoples diverse needs; such as their religion, race, age and disability. The home is good at supporting people to make their choices and decisions about their lives. This promotes peoples independence and helps make sure people follow the lives they wish. People have good access to occupation, education and leisure opportunities. The home is in a good place so that people can access the local community easily. People get good support to promote their health needs. Visiting professionals said the home is good at this. The manager had made the medication system safer for people. People were confident they could complain or share concerns, and staff and the manager would do something about it. Wellham House trained the staff so that the staff could identify bad practice and help keep people safe from abuse. People said they liked the homes environment. It was homely, comfortable and clean. People had nice bedrooms that were very personal to their preferences. People said they liked the staff. The inspector saw that staff were positive and they encouraged people. Staff were friendly and had a good sense of humour; people could enjoy fun and laughs at the home. Staff had training about peoples specific needs, this helped people get safe and consistent support. The organisation followed recruitment checks to help make sure people have safe support. People, relatives, professionals and staff said the manager managed the home well, they could approach her and she listened to what people had to say. DS0000065298.V332043.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Make sure there is always a medication stock audit trail so that the home can monitor correct use of medication. Make sure Milbury Care charge people for transport in a fair and consistent way. And they give people clear information about their transport charges. Never use people’s own money for the homes petty cash. Make sure the manager and Milbury Care have information about individual staff’s health; this will protect the people they support. Provide domestic washing machines to people who would benefit from them. This will promote people’s independence and dignity. Continue to provide access to staff to gain National Vocational Qualification in care until at least 50 of the care team have the qualification. This will help people to receive safe and consistent care. Milbury should make sure the manager has access to the Internet so that she can keep up to date with relevant care information. This will benefit people’s health, welfare and independence. DS0000065298.V332043.R01.S.doc Version 5.2 Page 8 Continue to improve the monthly visit reports so that they identify the homes areas for improvement and their progress better. This again will benefit the people who live at Wellham house. 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. DS0000065298.V332043.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 DS0000065298.V332043.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. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People who live at the home have their needs assessed, and staff review this so that they can continue to meet peoples changing needs. EVIDENCE: People had an assessment before they came to live at Wellham House. And the home looked at the assessments carefully before they decided if they could meet someone’s needs. They met and talked to the person interested in living at Wellham House and talked to their family and other professionals about the support the person needs. This was good practice and helped to make sure people got the right kind of support they needed. Wellham House also did their own assessment to make sure they understood more about peoples needs. They also sought advice if someone had complex needs. The assessments asked about people’s diverse needs; such as their religion, race, age and disability. DS0000065298.V332043.R01.S.doc Version 5.2 Page 11 Until the home had reviewed a persons needs, Wellham House kept preadmission assessment information available for staff to read. This was good practice because it helped staff understand peoples support needs until people had new support plans. Wellham House had staff who were trained and had good experience in assessments and assessment reviews. This included the manager and deputy manager. One person at the home said staff always discussed their support and assessments with them. This was good practice and helped to keep the person in control of their own support needs. DS0000065298.V332043.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 and 9. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People can make real decisions about their lives because the home follows good practices that include good support plans and supportive staff. EVIDENCE: People had support plans that contained a lot of information about their needs. Although there was a lot of information they were tidy and the information was easy to follow. The manager said she had just received new documents that should help people have better support plans. The new format should encourage a more person centred approach to the present plans. One person said staff told them about their support plan and staff explained what was in it. The person said, “They (staff) can only write positive things in it, and I can look at it if I want” DS0000065298.V332043.R01.S.doc Version 5.2 Page 13 The support plans included good information that was important to people’s daily lives, for example they had in them, ‘what people like about me’ and ‘what I must have’ and ‘I must not have’. This was very good practice to promote the important things in peoples daily lives. The plans included risk assessments and these helped people take reasonable risks, this helped people lead more independent and dignified lives. Wellham House followed good practices to encourage people to make decisions about their own lives. This included the risk assessments and records about what people liked and did not like. There was good evidence to show how staff had supported people to consider the consequences of the decisions they made. Examples of this were visual prompts for someone to refer to, staff, including the manager taking time to sit down and talk to people, and staff patiently allowing people to go over their decision again and again to give them reassurance. This was good professional practice that the home should continue to promote with staff. One person said as an outcome they felt “very happy, settled and safe”. One professional said in their survey about what the home does well, “They give people options and choices on how they wish to live” DS0000065298.V332043.R01.S.doc Version 5.2 Page 14 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. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People get good support to follow the daily routines they prefer; they have good support to access community, leisure and education opportunities. EVIDENCE: People said they were happy with their daily routines. They gave examples of the things they like to do such as shopping, going out to café’s, pubs and restaurants and going for walks. Wombwell shopping centre is close by and people said they liked to walk there and visit the shops. People had their individual routines and this included attending day centres, horse riding and activities in the home. Some people also had access to college and other education facilities. DS0000065298.V332043.R01.S.doc Version 5.2 Page 15 Wellham house offered people good community links, the home is well placed for this and staff made sure people accessed the places they wished. One member of staff said it is important to most people here that they get out and about. We try to do something every day. One professional said in their survey about what the home does well, They support individuals to pursue leisure and social activities which is of interest to them” There was good evidence to show that the home encouraged people to keep in touch with their family and friends. The inspector noted staff talked to some people a lot about their families, mentioning their names and confirming when they would visit. One family member said, “We visit Wellham House often and we are always welcomed in the same way, by a smile and a chat to discuss anything we have a mind to ask”. People said they were happy with the meals at the home. People could join in baking and cooking if they wished and made daily choices about what they wanted to eat. Staff had information about people’s special diets, this information and peoples food preferences were in their support plans. Where people needed more support and advice about their diet and condition the home had supported them with this. This was good practice; it promoted people’s health and wellbeing. The manager had made sure staff were aware of, and understood, new guidance about special diets. The inspector noted people who needed support to eat their meals got this from staff in a dignified way. For example the staff member sat with them, took their time, and checked what they preferred. DS0000065298.V332043.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 and 20. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People get good personal and health care support. The home has improved people’s safety and welfare by improving the medication system. EVIDENCE: A family member said about their relatives support, “The carers do a fantastic job in trying to understand them and for this reason they are mostly content”. One person said they had a set routine to clean and tidy their home, they liked this and said staff would help them if needed. People were able to get up, have baths and showers, and eat meals at the times they preferred. DS0000065298.V332043.R01.S.doc Version 5.2 Page 17 People had information about their health care needs in their support plans. This helped staff give people the right support to maintain their health. One person said staff always supported them to visit G.Ps and other health professionals and they were very happy about the way the staff did this. Wellham house had established good links with visiting health professionals and followed their advice and guidance. On behalf of the person, Wellham House invited appropriate professional people to reviews, for example they invited the community learning disability nurses (when this was appropriate). Health professionals said about Wellham House, “They are very proactive in seeking advice from other care professionals when needed” “They act appropriately when health needs arise, they seem to have good knowledge of the (people who live there)” “The manager contacts us and regularly gives us up-dates and information (about the person)” “Staff give appropriate and well informed information to clinics and allow the person to make their own decisions” The manager had reviewed the medication system, sought advice from pharmacists and changed the whole system to make it safer for people who need support with their medication. This was good proactive practice and showed the home put the health and safety needs of the people first. Pharmacists had recently advised the home about improved receipt, storage and administration of medication and staff had followed this. The manager continued to review this to make sure the system worked well. The home did not have an audit trail to check the running total of medicines in the home. This could mean medication could go missing and it would be difficult to investigate and follow up. DS0000065298.V332043.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 and 23. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. This judgement takes into account the good outcomes in other areas. However the area on finance needs rapid attention and improvement. People had information about how to complain. They had good support to help protect them from abuse. EVIDENCE: The home had a complaints procedure; this is available with the homes Statement of Purpose and was on display in the entrance hall. Two people told the inspector they were confident they could tell staff if they were not happy. One person said they had done this and were happy that staff and the manager listened to them. One relative said about the home, “We always observe and if anything was not to our liking we could pick up on the matter”. Wellham House had adult protection procedures available for staff to refer to. The manager said she had access to training to send staff on this coming year and this started in the very near future. Staff had had confirmation they were on the training and it was included in their rotas. DS0000065298.V332043.R01.S.doc Version 5.2 Page 19 People at the home said they felt safe and settled and staff spoke to and treated them well. The home had no adult protection referrals or received any complaints since the last inspection. The inspector checked three people’s finance records. On one record it showed that the home had used a person’s money for the homes petty cash. Although the home had paid the money back, borrowing people’s money for petty cash is bad practice and does not respect the rights of the individual. The manager agreed to follow this up with the staff concerned. The homes transport charges were not clear and the charges were inconsistent. For example the organisation charged people a transport fee, however they did not have good access to the homes vehicle because the home did not have many drivers. In addition to this the home had charged people from their spending monies (in addition to their transport fees) for taxis to attend hospital appointments. This was poor practice. This does not respect or safeguard peoples monies. The home should not charge for hospital transport unless it states this clearly in the persons contract, Statement of Purpose and Service User Guide. The manager was unable to produce a contract that showed how the home charges for transport. DS0000065298.V332043.R01.S.doc Version 5.2 Page 20 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, 26 and 30. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People live in a clean and comfortable home. It meets their needs and respects their preferences, dignity and safety. EVIDENCE: People said they were happy with the homes environment. One person said “I love it, I’m very happy” Another said “It’s lovely, I like it”. The home was clean, bright and welcoming. It had homely touches such as interesting pictures, photos and reference to important memories for people. DS0000065298.V332043.R01.S.doc Version 5.2 Page 21 The furniture and fittings were of good quality and suited the needs of the people who lived there. The home had put up a better gate in the kitchen, this allowed access for most people and kept others safe, who couldn’t understand kitchen dangers. People said they were very satisfied with their bedrooms. The inspector visited three bedrooms; these were very personalised to people’s individual preferences. The laundry was clean and has suitable equipment to meet people’s laundry needs. People’s clothes looked like they were laundered with care. The home had some accommodation designed for people with more independent skills. They did not have domestic washing machines, although there was the space to fit them. The manager confirmed that someone might benefit from this in the near future. The home should consider installing the washing machine now ready for when the person can use it. This will give the home time to sort out any plumbing or fitting problems that may occur. DS0000065298.V332043.R01.S.doc Version 5.2 Page 22 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 and 35. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People get support from staff who understand their roles and can give safe and competent support. In the main the recruitment process helps to keep people safe. EVIDENCE: Staff were knowledgeable about peoples care, they understood about the support plans and what they needed to do to support people in their daily lives The inspector noted people and staff laughing together. The staff were friendly and lively in their approach. They gave people a lot of attention and in the main they were patient and positive. A relative described the staff as doing “a fantastic job” and said the home has “great staff”. Six out of sixteen staff have a National Vocational Qualification in care; and three more staff are nominated for the training. DS0000065298.V332043.R01.S.doc Version 5.2 Page 23 NVQ qualifications enable teams to give people up-to date and consistent support. The inspector checked three recruitment files. These showed that in the main the home had followed robust procedures to make sure they employ the right staff. However, in two files there was no evidence that the home had a statement on the staffs’ mental and physical health. If the manager does not know about staff health needs that might affect their work, it could put people at risk. The manager had a rolling program of training for staff, this continued through out the year and identified staff who needed training. In the past year staff had had access to training specific to peoples needs such as epilepsy training. DS0000065298.V332043.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The manager has good skills and qualifications to manage the home well. And has continued to attend training to keep up with current good practice. This includes training on risk assessing management, protection of vulnerable adults and safe administration of medicines. Staff said the manager was very supportive and a relative described the manager as “brilliant”. The home had quality assurance systems in place. These included maintenance checks, staff supervision, consulting with relatives and feedback from professionals. DS0000065298.V332043.R01.S.doc Version 5.2 Page 25 The organisation Milbury Care carried out a visit and report about once a month. They supplied the Commission for Social Care Inspection with the outcome of the report. In the past the report gave very little information about the homes progress and about peoples views. However the last report submitted contained better information. This was improved practice because it showed the organisation aimed to be more transparent and open about its findings. The inspector encourages the organisation to continue to improve this practice. The manager did not have Internet access at the home. This meant it was difficult for her to keep up to date with current events and information. For example there is frequent information on the Commission for Social Care Inspection and Department of Health websites about changing and good practice guidance. The home had good evidence to show it monitored health and safety. This included records on fire and maintenance checks, policy and procedures on health and safety and staff training. The manager confirmed staff were on a rolling programme to attend safe working practice training. This helped make sure staff were up to date and understood current and new safe working practices. (Safe working practices include fire, food hygiene, first aid, moving and handling and infection control). DS0000065298.V332043.R01.S.doc Version 5.2 Page 26 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 3 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 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 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 X 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 3 X DS0000065298.V332043.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13.2 Requirement There must always be a stock audit trail on medication. This will help make sure the home can account for all medicines that enter the home. 2 YA23 13.6 Staff must not use peoples’ personal monies as a loan to the homes petty cash system. The organisation must review transport charges and make sure the charges for transport are fair, consistent and stated in people’s terms and conditions. The organisations transport fees must be included in the Statement of Purpose and service user Guide. The information must be clear and transparent. 3 YA34 19.1(a)(b) When recruiting staff the home Schedule 2 must get statements about staff physical and mental health. 30/06/07 30/06/07 Timescale for action 30/06/07 DS0000065298.V332043.R01.S.doc Version 5.2 Page 28 If the organisation does not keep these at the home there should be documentary evidence that they have a statement in their possession. 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 YA23 Good Practice Recommendations The regulation 26 reports (monthly visit reports) should include information on the action the organisation has taken to make sure people’s finances are used appropriately including transport fees. This should continue until the next inspection. This will enable the home to demonstrate that they have taken appropriate action to safeguard peoples own monies. 2 YA24 The home should provide domestic washers to people who would benefit from them. This will promote people’s independence and dignity. At least 50 of care staff should have a National Vocational Qualification in care at level 2 or above. The manager should have access up to date with relevant care information. For example the CSCI and department of health website. 5 YA39 Milbury care should continue to review and improve their monthly visit reports so that they provide clear and transparent information about the homes progress. This will benefit the people who live there because it will show where the home has identified areas for improvement and what action they take about it. 3 4 YA32 YA39 DS0000065298.V332043.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000065298.V332043.R01.S.doc Version 5.2 Page 30 - 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. 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