Inspection on 25/09/07 for Willow Garth Care Home

This inspection was carried out on 25th September 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Willow Garth Care Home 23/09/08

Willow Garth Care Home 26/09/06

Willow Garth Care Home 12/12/05

Willow Garth Care Home 04/05/05

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Willow Garth Care Home Rolston Road Hornsea East Yorkshire HU18 1XP Lead Inspector Rob Padwick Key Unannounced Inspection 25th September 2007 2:30 DS0000062723.V351372.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 DS0000062723.V351372.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. DS0000062723.V351372.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow Garth Care Home Address Rolston Road Hornsea East Yorkshire HU18 1XP 01964 534651 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) hatzfeldcareltd@btconnect.com Hatzfeld Care Limited Mrs Ann Lesley Sykes Care Home 28 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (40), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) DS0000062723.V351372.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Category MD(E) is restricted to three individuals named to CSCI on 19.5.06. This condition will cease when those named no longer live in the home. From the date of this certificate the service may provide care and accommodation for a maximum of 28 (twenty-eight) persons in the permitted registration categories. On completion of Phase 2 alterations to the premises, and subject to confirmation by the Commission for Social Care Inspection that evidence of compliance with all necessary regulations and standards has been received, the service may provide care and accommodation for a maximum of 33 (thirty-three) persons in the permitted registration categories. On completion of Phase 3 alterations to the premises, and subject to confirmation by the Commission for Social Care Inspection that evidence of compliance with all necessary regulations and standards has been received, the service may provide care and accommodation for a maximum of 40 (forty) persons in the permitted registration categories. Agreements detailed in conditions 3 and 4 will cease on 31 March 2008 whereafter any variation to registration will require a further application to the current regulatory authority. 26th September 2006 4. 5. Date of last inspection Brief Description of the Service: Willow Garth is located in a rural setting close to the town of Hornsea on the East Riding of Yorkshire coast. The home is registered for 33 service users (male and female) who have mental health needs. Personal support is provided for service users along with all meals and a laundry service. Service Users have access to the home’s minibus for outings and shopping, since access to local facilities in the nearby town is via bus journey, although many choose to walk along a badly lit road. The home is currently in the process of being upgraded with the development of additional bedrooms, which are sited in the grounds close by to the main home. Accommodation in the pre existing building is in 17 single and 3 shared rooms, which are situated on two floors. 10 additional bedrooms are provided in ground floor chalet-type accommodation that are equipped with ensuite toilet and shower facilities. There is no passenger lift available in the home. Communal space is available in the homes dining room and two recently developed conservatory lounge areas, one of which has been designated as a DS0000062723.V351372.R01.S.doc Version 5.2 Page 5 smoking area. The standard fees charged by the home range from £350 to £590 with additional charges made for hairdressing, toiletries and other amenities. Willow Garth provides information about the home to service users in its Statement of Purpose and Service User Guide. DS0000062723.V351372.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last key inspection of the home on 26th September 2006, including information gathered during a site visit to the home A questionnaire asking for information about the service was sent to the provider before the inspection visit and this was returned to the Commission for Social Care Inspection with the electronic signature of the Registered Manager who had been absent from work for a number of weeks before hand. Other information used, included feedback from questionnaires sent out to people living in the home, their relatives and professional staff who know them well, together with official notifications received by the Commission for Social Care Inspection about the home. The inspection visit for this service lasted for 5 hours and during this period, time was spent talking with people living in the home and observing their daily lives. Other time was spent looking at their care plans and other records and talking to staff. The inspection visit also included a tour of the premises. What the service does well: What has improved since the last inspection? Staff had been provided with training in the safe use and handling of medication to ensure that the medical needs of people living in the home are more safely met and a training plan had been developed to ensure they could do their jobs. Opportunities had been developed to enable people living in the home to have a greater variety of choices about their lives and further improvements had been made to the home’s facilities to ensure the environment was able to meet their needs. A staff member had been appointed to ensure that the upkeep of the building was maintained. DS0000062723.V351372.R01.S.doc Version 5.2 Page 7 What they could do better: 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. DS0000062723.V351372.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 DS0000062723.V351372.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 and 2 People who use this service experience poor outcomes in this area. The assessment process of people living in the home was not robust enough to ensure it could safely meet their needs and information about the service was not sufficiently accurate to enable people make an informed choice about using the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home indicated that they or their representatives had been provided with information about the service, in order to help them make a decision about moving into home. A copy of the home’s Statement of Purpose submitted to the Commission for Social Care Inspection on the 7th August 2007 did not include key information or specialist forms of support that the service claims to provide. A copy of this document issued to health professionals associated with the home however, stated the home cares “for people with Wernicke- Korsakoff syndrome and all their associated needs”. However, no specialist training linked to this condition had been provided to staff, although the provider stated one staff member had previously gained previous experience of this. The differences in these documents could lead to confusion about the purpose and capacity of the service to provide specific types of care. People living in the home had generally been assessed as part of their admission process, so it was possible to determine the service could suitably meet their needs. However, the case files of the two most recent admissions DS0000062723.V351372.R01.S.doc Version 5.2 Page 10 indicated this process needed to be carried out more robustly. The case file of one person contained a pre assessment completed by a health professional that highlighted specialist needs staff had not received appropriate training about, whilst no assessment information was available for the other individual, to confirm that the home was suitable to meet their needs. This means people living in the home may be put at risk due to staff not having sufficient skills to support their individual needs safely. DS0000062723.V351372.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 and 9 People who use this service experience adequate outcomes in this area. People living in the home were involved in making choices about their needs and wishes, however shortfalls in care planning and risk assessments meant staff did not always have sufficient information to support them with these. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We spoke to people living in the home who confirmed they were happy living at Willow Garth and the way that staff supported them. Comments received from some however, indicated they would like more support but that the needs of others sometimes limited the amount that staff could provide. Information provided by the manager indicated since the last inspection visit, people living in the home had been provided with greater opportunities to become more involved in making choices about their lives and comments received from professionals associated with the home confirmed this aspect of the service had generally improved. People confirmed they were involved in making decisions about the home and confirmation of this was contained in the minutes of meetings held with them. Some people indicated they helped out DS0000062723.V351372.R01.S.doc Version 5.2 Page 12 with jobs around the home and doing things like cleaning and working on the building projects for which they received “therapeutic earnings” to help buy things like cigarettes. People indicated they were aware of their care plans, although it was not always possible to check their active involvement in these, as they were not always dated or signed by them. The case files of three people living in the home, contained basic care plans developed around aspects of their health, personal care, social activities and finances. Details of the type of support needed from staff was on the whole fairly sketchy and unclear, whilst the case file belonging to the most recently admitted person, contained an only partially completed further assessment of need and care plan, despite the provider having agreed to undertake this within a week of admission, owing to their complexity. This means that people living in the home were potentially placed at risk of harm owing to staff not always having clear information about them. Aspects relating to the management of risk to people living in the home were contained in the case files inspected and discussion with people living at Willow Garth confirmed they were in agreement with these and that they were supported to take responsibility for their decisions. Some of the risk assessments however, had not been fully completed or provided sufficient information to staff about what to look out for and do in respect of these matters. A requirement is therefore made about this. DS0000062723.V351372.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 People who use this service experience good outcomes in this area. Some lifestyle opportunities were available for people living in the home, although the management of these needed improving to ensure that their individual needs are better met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We spoke to people living in the home who confirmed that opportunities existed for them to make lifestyle choices. The home has a mini bus for trips out and visits to places of interest and people living at Willow Garth were observed being invited to go on an outing to Scarborough due to take place in the near future. Comments received from some people living in the home however, indicated that they were not able to use the minibus as often as others, whilst another indicated the relatively isolated location of the home made it difficult to have visitors and that it was not easy to get into the local town as it was “too far to walk to the shops”. A health professional commented that the needs of the mixed group of people living at Willow DS0000062723.V351372.R01.S.doc Version 5.2 Page 14 Garth sometimes resulted in their “individual needs not always being considered”. A recommendation is made in these respects. Routines in the home are kept flexible with people living at Willow Garth able to choose what to do within reason. Information provided in the AQUA (self assessment) indicated the amount of activities available had increased since the last inspection and that plans were in place to look at “starting staff and resident competitions with small awards, starting a worm farm, obtaining chickens and a pig for the small holding that the residents will take part in the care of”. A mental health worker stated the home had “started to respond more to the needs of people with severe and enduring mental illness…this group have a better quality of life”. Questionnaires from the three relatives that replied to questionnaires sent out highlighted general satisfaction with the home. One stated, “I am satisfied with the care home, it is much improved”, whilst another commented “my brother is very happy…I see him every fortnight sometimes weekly”. Care plans provided confirmation of support to maximise independence and daily living skills and discussion with people living in the home confirmed they enjoyed doing jobs around the home. Kitchen records contained evidence that people living in the home were provided with a healthy diet and comments received from them indicated that the food was “excellent” whilst those spoken to said they were able to help choose what was to be served. DS0000062723.V351372.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 People who use this service experience adequate outcomes in this area. Whilst the individual health and personal care needs of people living in the home were being met, improved communication with professionals would enable staff to support them with these better. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We spoke to people living in the home who told us their health and personal care needs were being appropriately met. Comment cards received indicated they generally felt they were listened to and that staff treated them with respect. People living in the home are largely independent in terms of their personal care needs and case files inspected contained evidence of basic guidance and support needed to enable them to maintain and develop these skills. The health and psychological needs of people living in the home cover a wide range of medical conditions. Information about these was included in the care plans inspected, but as indicated previously, these needed further development to ensure staff are equipped with accurate and clear information about the type of support required. Case files contained evidence of monitoring and staff actions relating to the health of people living in the home and comments received from professionals associated with Willow Garth were generally favourable, although some indicated better communication was DS0000062723.V351372.R01.S.doc Version 5.2 Page 16 needed at times. Following a concern received by the Commission for Social Care Inspection, and despite staff having received training in the administration of medication to people living in the home as previously required, a recent visit from a Pharmacist Inspector had resulted in requirements and recommendations being made. Discussion with a senior staff member indicated that following the above visit, the local pharmacy had been contacted and that individual pre packed dossette boxes were now supplied for those administering their own medication and that up to date MAR charts had been obtained. However, another requirement relating to the need for care plans to be kept up to date about changes in medication and communication with members of the medical team so staff can be kept better informed about these was still unmet. A random inspection of the medication charts indicated that these were being completed satisfactorily, however recommendations concerning the need for risk assessments to be kept up to date for those self administering their own medication, and for a system to be developed to record medication received by the home had not yet been implemented. DS0000062723.V351372.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 People who use this service experience good outcomes in this area. Staff had been provided with training to ensure people living in the home were safeguarded from abuse, however some people did not always feel their concerns would be taken seriously. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living in the home who we spoke to were largely satisfied with the service although comments received in questionnaires from some were mixed in nature. Some people made comments that it is a “very good home with lovely staff” whilst others expressed issues about the standard of cleanliness and highlighted problems connected with the management of the mixed needs of people living in the home. The home had an acceptable policy to ensure the views of people living in the home would be listened to and taken seriously and the home’s complaints book contained evidence of actions taken to resolve the 11 complaints made about the service since the last inspection. However despite a previous recommendation about this, some comments received from people living in the home indicated continued levels of uncertainty about the operation of this. A further recommendation about this is therefore made. Discussion with the provider indicated that one of the people living in the home acted as receiver for complaints about the service. Policies and procedures were in place to ensure that people were safeguarded from harm and evidence was seen in the staff files that training had been provided to ensure staff knew what to do should they have any concerns in these respects. A random sample of records of monies belonging to people living in the home that were examined indicated that people were receiving DS0000062723.V351372.R01.S.doc Version 5.2 Page 18 their weekly benefit entitlement and that some received a “therapeutic allowance” from the provider for assistance with jobs carried out around the home. The records inspected also highlighted a loan system that had been developed to enable people living in the home to pay for expensive items (e.g. a personal television) that had been bought for them by the provider. DS0000062723.V351372.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use this service experience good outcomes in this area. The environment for people living in the home was generally good, however further improvements to the facilities were needed to ensure that it was clean and safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Comments received from people living in the home and those associated with it indicated that service provided a comfortable and homely environment. Buildings were observed to be generally clean and tidy, although comments received in questionnaires returned from some people living in the home indicated that improvements to this aspect of the service were needed. The registered provider indicated that the service was without a housekeeper at the time of this inspection visit and a recommendation is therefore made about this. Since the last key inspection, work had been completed to develop a further block of five bedrooms and information provided as part of the inspection process indicated that a maintenance person had been appointed to ensure the upkeep of the building. However, one of the toilets in the older part of the home was out of use at the time of this visit and a requirement is DS0000062723.V351372.R01.S.doc Version 5.2 Page 20 therefore made about this. Similarly, a previous requirement relating to the need for the driveway to be adequately lit, in order to ensure the safety of people living in the home had still not yet been implemented and this is therefore repeated. DS0000062723.V351372.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 People who use this service experience poor outcomes in this area. The home’s recruitment procedures ensured staff had been checked to ensure they were safe to work with people living in the home. However the currents levels of staffing and some staff training shortfalls were not consistently meeting their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at Willow Garth who we spoke to were generally satisfied with the support received and comments received from their relatives were very supportive of the home and the staff. A requirement was made at the last inspection to ensure that sufficient numbers of staff were on duty to meet the needs of the people living in the home. The service had obtained information from the Staffing Forum to assist with the identification of the recommended staffing levels for the service. However from observation and comments received from those living in the home, professionals associated with it and in comments received from staff, this situation continues to be an area of serious concern. Information provided by the manager indicated that two staff members had left during the past year and evidence was seen of action taken to recruit additional staff, although these were not yet in post. The staffing levels at the time of this visit of two care staff, plus a cook and the Provider DS0000062723.V351372.R01.S.doc Version 5.2 Page 22 who was on duty restricted the ability of the service to deliver appropriate person centred support and this requirement is therefore repeated in order to ensure those living in the home are safeguarded against risk of harm. Comments received in the staff questionnaires indicated high levels of commitment to meeting the needs of people living at Willow Garth and evidence was seen in the file of the most recently recruited staff member, of an appropriate induction programme, together with evidence of other mandatory training. A training plan for the staff team as a whole was not available for inspection at the time of this visit, but a copy of this that was subsequently received indicated a plan had been developed to ensure staff were provided with training to do their jobs. However, inspection of this plan indicated that only one staff member had undertaken specialist training relating to the mental health needs of those living in the home, and a requirement is therefore made about this. The service had recruitment policies and procedures to ensure staff were safe to work with people living in the home. Evidence was seen that the manager had obtained references and documentation to confirm the identity of the one staff member employed since the last inspection visit and that a check had been made against the Protection of Vulnerable Adults list (POVA First) before allowing him to start work in the home. Satisfactory clearance had subsequently been received from the Criminal Records Bureau. The provider was reminded that staff must only in exceptional circumstance be allowed to commence work in the service before a Criminal Records Bureau check is received for them and that until this point, they should be supervised at all times. DS0000062723.V351372.R01.S.doc Version 5.2 Page 23 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 this service experience adequate outcomes in this area. Administrative systems were in place to ensure that people living in the home were consulted about the service, however aspects’ relating the management of their safety did not ensure this was being sufficiently promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at Willow Garth who we spoke to were largely satisfied with the management of the home, although some mixed responses were received in questionnaires returned from them as apart of the inspection process. Since the last inspection visit, the home manager had been registered with the Commission for Social Care Inspection, although at the time of this visit she was reported by the Registered Provider to have been off sick for a number of weeks. A new deputy manager and administrator for the home had been appointed and evidence was seen of improved office and management systems DS0000062723.V351372.R01.S.doc Version 5.2 Page 24 to support the running of the service. Quality Assurance systems had been developed and evidence of regular monitoring and audits of various aspects of the home were seen, together with systems for consulting people who are living in the home. Information provided in the AQUA (Self assessment) indicated that a firm of specialists provide support to ensure the health and safety of people living in the home and those records that could be checked, contained evidence that equipment was being appropriately maintained. However, some aspects relating to the safety of people living in the home highlighted that this aspect of the service needed to be managed more robustly. These included an outstanding requirement for more staff to be on duty, together with the need for improved record keeping and systems for managing risk to people living in the home. Specialist staff training was similarly required in order that the individual needs of people living in the home can be better met. DS0000062723.V351372.R01.S.doc Version 5.2 Page 25 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 1 2 1 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 2 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 1 X DS0000062723.V351372.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA1YA1 Regulation 4 Requirement The registered provider must ensure that an up to date Statement of Purpose is available so people have accurate information to help them make an informed choice about the home The registered person must ensure that the needs of people living in the home are fully assessed before they move in so that it is possible to determine that the service can safely meet their needs The registered person must ensure that care plans for people living in the home are developed to include accurate information about their individual needs and wishes so that staff have details about the type of support that is required to support them The registered person must ensure that risk assessments are kept up to date and contain clear information about what staff should look out for and do in order to ensure that to people living in the home are safeguarded from harm DS0000062723.V351372.R01.S.doc Timescale for action 25/12/07 2. YA2YA2 14, 15 25/09/07 3. YA6YA6 14, 15 25/12/07 4. YA9YA9 13 (2,4) 14 (2) 25/11/07 Version 5.2 Page 27 5. YA20YA20 17 Sch 3 6. YA24YA24 13,23,39 7. YA24YA24 23 8. YA33YA33 18 (1) (a) 9. YA35YA35 18 (1) (c) 10. YA42YA42 12 Care plans should be updated to include changes to medication and communication with members of the healthcare team providing care to the person. This makes sure that there is up to date and accurate information about a person’s medical condition. (Previous timescale of 17/08/07 not met) The registered provider must ensure that the driveway to the home is adequately lit. (Previous timescale 01/11/06 and 17/08/07 not met) The registered person must ensure that action is taken to repair the out of use toilet in the home in order those living in the home have adequate facilities The registered person must ensure that there are sufficient staff on duty at all times to meet the needs of the residents accommodated in the home (Previous timescale of 15/10/06 and 17/08/07 not met) The registered person must ensure that staff receive specialist mental health training in order that they can support the needs of people living in the home The registered person must ensure that the health and safety of people living in the home is managed effectively 25/11/07 25/12/07 25/12/07 15/11/07 25/12/07 25/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. DS0000062723.V351372.R01.S.doc Version 5.2 Page 28 No. 1. Refer to Standard YA6YA6 Good Practice Recommendations The registered person should ensure that the care plans of people living in the home are signed by them and kept up to date, so that it is possible to confirm their active involvement and agreement with them. The registered person should ensure that opportunities for people living in the home are developed further to enable their individual lifestyle choices to be better met The registered person should update the home’s medication policy to ensure staff are working to current legislation and guidance. The registered person should ensure that a system is in place to record all medication received in to the home and medication carried over from the previous month. This helps to confirm that medication is being given as prescribed and when checking stock levels. The registered person should ensure that risk assessments are maintained and updated for everyone who selfadministers their medication. This makes sure that the medication is taken correctly and safely. The registered person should review the system for making complaints about the service so that people living in the home are assured that their concerns will be listened to and acted upon The registered person should ensure that a housekeeper is appointed for the home in order to ensure that the environment for people living in the home is kept clean and tidy at all times The registered person should ensure that 50 of the care staff have obtained an NVQ level 2 in care. The registered person should ensure that the manager completes her Registered Managers Award 2. 3. 4. YA12YA12 YA20YA20 YA20YA20 5. YA20YA20 6. YA22YA22 7. YA30YA30 8. 9. YA32YA32 YA37YA37 DS0000062723.V351372.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000062723.V351372.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!