Care Home: 94 Chatsworth Road

Similar services:

• Polesworth Group Friary Road
• Polesworth Group Pooley Heights
• Polesworth Group 32 Station Road
• Polesworth Group 70 Long Street
• Breme
• Polesworth Group 64 Long Street
• Polesworth Group 68 Long Street
• 10 Whitfield Avenue

What the care home does well New people are supported to visit and try out the service before moving in. People`s needs and wishes are written in their care plans. They are supported to have their health and physical care needs met in the way they prefer. People can spend time doing things they like at home and in the community. They are supported to stay in touch with their families. People have a comfortable and safe home that has been adapted to meet their needs. Each person has their own single bedroom with their own things. Their medication is being safely managed. All the staff are qualified and the team is small so staff get to know the men well. They benefit from a service that is well run. What the care home could do better: Each person should have a health action plan. Some records could be improved to better protect people. Methods of checking on the quality of the service could be improved. The manager needs to give better information to the commission in the future. CARE HOME ADULTS 18-65 Chatsworth Road 94 Westfields Hereford Herefordshire HR4 9HZ Lead Inspector Jean Littler Unannounced Inspection 23rd February 2008 15:30 Chatsworth Road 94 DS0000024688.V355689.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 Chatsworth Road 94 DS0000024688.V355689.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. Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chatsworth Road 94 Address Westfields Hereford Herefordshire HR4 9HZ 01432 340560 01432 340560 chatsworth.road@aspirechoices.com 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) Aspire Living Ceridwen Jones Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. None. Date of last inspection 25th October 2006 Brief Description of the Service: 94 Chatsworth Road is a service run by Aspire Living and Choices Ltd. which is a Voluntary Organisation. The head office is based at the Fred Bulmer Centre, Wall Street, Hereford, HR4 9HP. The Care Home provides personal care, social support and accommodation for four adults with learning disabilities, some of whom also have physical disabilities. The accommodation is provided in a purpose built bungalow within a modern housing development in Hereford. There are pubs, local shops, a supermarket and post office all within a short distance. Transport for longer distances is provided in the Homes unmarked minibus. The house contains four single bedrooms, communal rooms and an assisted bathroom and shower room. Information about the Home is available from the Head Office or the Care Home on request. The Home has a block contract with Hereford Local Authority, which means the fees are set and only people funded by Hereford can be placed in the Home. In 2006 the weekly fees were £1202. Details of the updated fees were not available during the inspection. Additional charges are charged for personal items such as clothes and toiletries, and personal services such as haircuts and chiropody, holidays, some activities, vehicle hire and running costs and specialist equipment if the person has more than £1000 savings. Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was carried out over 3 hours in the afternoon. Two support staff were on duty and helped with the process. We spoke with both staff and looked around the house. Three people showed us their bedrooms. Three relatives of people who live in the Home professionals filled out surveys to give us their views. and two We looked at some records such as care plans and medication. The manager sent information about the Home to us before the visit. What the service does well: New people are supported to visit and try out the service before moving in. People’s needs and wishes are written in their care plans. They are supported to have their health and physical care needs met in the way they prefer. People can spend time doing things they like at home and in the community. They are supported to stay in touch with their families. People have a comfortable and safe home that has been adapted to meet their needs. Each person has their own single bedroom with their own things. Their medication is being safely managed. Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 6 All the staff are qualified and the team is small so staff get to know the men well. They benefit from a service that is well run. What has improved since the last inspection? 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. Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 7 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 Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 8 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, 3, 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. People interested in using the service would have their needs assessed by an external person and would be enabled to visit the home and trial the service before moving in. EVIDENCE: The same four people are resident in the Home. The placement of the person who moved in most recently was made permanent in June 06. He had been staying for some respite care so he had a slow transition into the service, which was positive for him. The assessment process was looked into at the last inspection. An assessment of the man’s needs had been provided by the social worker and his next of kin had provided information. The manager, Mrs Jones, had not collated her own assessment or summarised the information she had collected to show that his needs could be met before he was admitted. She reported in the Annual Quality Assurance Assessment (A.Q.A.A. which is information registered people have to provide to the commission), that she would carry out an assessment before anyone was offered a placement in the future. Information about the service is available in the form of a Statement of Purpose and a Service User’s Guide. Mrs Jones did not mention in the AQAA if she has kept these under review. She reported after the inspection that representatives of the residents had signed the Terms and Conditions of Residency on their behalf in 2006. Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. People’s needs are recorded in their care plans and these are being kept under review. People are being supported to make some decisions. They may be able to become more involved if communication methods are further developed. They are being enabled to take reasonable risks in order to enjoy their lives. EVIDENCE: Care plans are in place for all four men. Those sampled contained relevant information to guide staff about each person’s needs including sections about personal care, regular activities and personal preferences. The plans contain goal plans that are being worked towards to assist people to become more independent. These reflect their abilities and are considered quite long term. Health sections are in the care plan but person centred health action plans have not been implemented. Risk assessments have been carried out with the support of the organisation’s health and safety officer. The sample seen showed that reasonable judgements were being made to balance safety and quality of life. Mrs Jones reported in the AQAA that this year a lot of work has gone into updating the care plans and ensuring they reflect people’s needs. Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 10 There was evidence that each section had been reviewed periodically. She also reported that review meetings had been held six monthly for each person. Feedback in surveys was positive and representatives felt people’s needs were being met. One said staff occasionally forgot to invite her to review meetings. The plans have not been developed into an assessable format. Some of the men may not be able to understand the content of their plans in any format however at least one would. From the care plan folders it was not clear what person centred planning had been carried out. One mentioned two circle of friends meetings being arranged but no outcomes were found. Staff on each shift complete daily care records. The notes are brief but several charts are also used to record information about personal care and health issues. This information creates a picture of the people’s overall wellbeing. The level of recording about activities should be increased to help keyworkers judge what activities to prioritise when people are unable to make clear choices for themselves. Staff were observed to offer people choices during the inspection in a way that was meaningful to the person. For example one person indicated that he wanted to stay in his room after he had shown it to us so the worker provided him with sensory equipment, which he enjoyed holding. The organisation’s communications facilitator has supported the team to complete communication profiles for people to help staff understand what they are communicating. Some communication systems are in place e.g. pictorial menu cards. Mrs Jones did not mention in the AQAA if any of these had been further developed as suggested at the last inspection. Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. People are being provided with appropriate outings in the community and in-house activities. Good support is being provided to help people stay in touch with their relatives. A balanced and healthy diet is being provided and mealtimes are relaxed and homely. EVIDENCE: The people living in the home seemed very relaxed and happy during the inspection. One was playing his keyboard in his room, two were watching television and the fourth was listening to music in his room. Later they had their evening meal, the light meal of the day, in front of the television. Both workers communicated in a calm and pleasant manner and seemed attentive to the men’s needs. Each person has an activities plan. These are displayed on the office wall and they showed that each person is taking part in a variety of different outings and activities e.g. listening to live music sessions at the Courtyard Theatre and visits to a snoozalem. In-house activities include music sessions, wine making, Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 12 and hand massages. A worker discussed activities but was unsure why some of the men have planned time to take part in shopping trips and others did not. The daily records were brief and did not report if each activity attended had been of benefit to the person. The worker did not seem familiar with the practice of daily monitoring records being used to inform the care planning process. Feedback from surveys was positive about people’s lifestyles. Two representatives felt more outside activities could be accessed. One suggested the budget needed increasing to enable this. The other felt there was a lot of focus on set weekly activities that may become boring rather then arranging outings to places of interest and short breaks away. Mrs Jones reported in the AQAA that every effort is made to find suitable activities for the men. She gave some examples e.g. two staff now support one person to attend a trampolining session, the rota was changed so one man can go to an evening activity, one person has been supported to meet with outside agencies to try and improve disabled access facilities at a local pool. She did not explain if holidays are being arranged. They have been in the past but there was an issue of funding for staffing costs that arose last year. The sample of care plans seen showed that development goals had been identified for each person. These seemed to mainly focus on basic life skills. Staff complete daily tick charts to report on these. One goal had been stopped and a new goal introduced for the person, but there was no explanation as to why one had stopped and whether this was because he was now independent in that area. Staff were seen to encouraged one man to put his cup in the sink and another was supported to feed himself. People’s relationships with their friends and relatives continue to be encouraged. Survey feedback confirmed that visitors are made welcome. One person attends a weekly club where he spends time with his brother. The food is purchased locally and staff prepare fresh meals daily. Records showed a balanced and varied diet is being provided. There are no set times for meals, and drinks and snacks are available throughout the day. Any limitations are on health grounds. The evening meal was eaten in a relaxed atmosphere with the staff eating as well. People’s general preferences are known and considered when meals are prepared. Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. People are having their health and care needs met in a personalised and flexible manner. Medication is administered safely. EVIDENCE: The care records are being written in an appropriately respectful way and staff were observed to interact with the men in a pleasant manner. People have their own bedding and towels and are supported to bath or shower each day. Records showed that the daily routines are flexible and seem to take account of people’s needs, preferences, age and health. Where possible they are given choices e.g. about getting up and how to spend their time while at home. The staffing arrangements do not allow same gender personal care to be given as the majority of staff are female. Self-help skills are being promoted through goal planning. Feedback from surveys was about how people’s health and person care needs are being met and they are informed appropriately about any health concerns. Mrs Jones reported the following in the AQAA, ‘There are procedures for working with and all healthcare needs for service users are recorded in their individual files. One service user has a pressure care assessment twice yearly and the district nurse is asked to record the outcome in the appropriate section Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 14 within the care plan. Staff then record in the diary when the next assessment is due as are other future appointments. The GP at the surgery used by three of our service users has refused to give them annual health checks so we have got him to put it in writing and filed it in individual care plans. There have not been any accidents or incidents that have required admission to A&E. Serious health concerns in the past have been managed well and appropriate professional support requested in a timely manner e.g. occupational therapy assessments for equipment. It would be positive if person centred preventative health action plans were developed as part of the care plans. People can then take these with them if they leave the service. Medication was being securely stored. Records were clear and showed that doses had been given as prescribed. One medication is in stock in case of emergency as the person has epilepsy. This is now a schedule 3 controlled drug and it is recommended that a CD register is used to help keep a good audit trail for this product. People are having their medication reviewed by the doctors involved. Protocols are in place to guide staff in the use of emergency medication and the health specialist involved has approved these. All staff administer medication and they were due to attend accredited training in Safe Handling of Medicines at the time of the last inspection. Recommendations were made that stocks of medication held in a separate cabinet were included in the stock taking process and that a record is kept of competency checks Mrs Jones carries out on staff. Mrs Jones did not mention medication in the AQAA and the staff on duty did not know what arrangements were in place. The recommendations have therefore been brought forward. Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There are systems in place to enable people or their representatives to raise concerns. A framework is in place to help protect people from abuse. EVIDENCE: Mrs Jones said in the AQAA that no complaints have been received by the service since the last inspection. The commission has received none. The service has a complaints procedure. Efforts have been made to help people understand their right to make complaints e.g. happy and sad faces are used as a communication aide. Each person does have someone outside the home to advocate on his behalf and keyworkers also have this role. The feedback in surveys showed that people’s representative know how to make a complaint. All have confidence that Mrs Jones will respond positively to concerns and try to address them. One person lacked confidence in the abilities of more senior people in the organisation to respond to issues that are raised. A protection policy is in place, which reflects the local multi-agency Vulnerable Adult guidelines. No protection issues have been raised since the last inspection. Adult Protection is covered during the induction and the Learning Disability Award Framework. Mrs Jones reported in the AQAA that staff have to sign to show they have read the policy. She did not provide information about whether staff are provided with any specific training course on adult protection. She did say she keeps risk assessments under review and the staff recruitment practices have been improved to help safeguard people. The staff spoken with said they would report any concerns to the manager. Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 16 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, 26, 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. People have a clean and well-maintained environment that has been attractively decorated and comfortably furnished. Their bedrooms are personalised and specialist equipment has been provided to meet their needs. EVIDENCE: The Home is situated near to Hereford town centre and the local amenities. The bungalow has level access with wide corridors and doorways throughout to take account of the needs of people who use wheelchairs. There are four single bedrooms with sinks. The bedrooms are smaller then the standards recommended for people who use wheelchairs but the total average living space exceeds the standard so this compensates to some degree. Communal facilities consist of a lounge, an open plan dining area and kitchen, a laundry, a toilet, an adapted bathroom and separate level access shower-room. The lounge leads onto a patio area and the garden that has been fitted with some adapted equipment. Opened in 1996 the premises met relevant building regulations at that time. Fire prevention and alert systems are in place. Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 17 The house is homely, modern and attractively decorated. People’s bedrooms are individually decorated and comfortably furnished. One person had a new specialist bed. They are fitted out with personalised items to enable people to use them independently e.g. have time alone to listen to music and use sensory equipment. The manager has consistently ensured that the environment is kept at a high standard by arranging regular redecoration and for any necessary adaptations to be made to meet people’s physical needs. She reported in the AQAA that ceiling-tracking hoists are now fitted in two bedrooms and the bathroom. She is aware that there is a shortage of storage space particularly for large pieces of equipment such as hoists. She has appropriately consulted occupational therapists when equipment and adaptations have been considered. A new cleaner has been recruited to support staff in keeping the house clean. All rooms were clean, tidy and fresh. The laundry is suitably equipped and systems to reduce the risk of cross infection are in place e.g. protective clothing. Feedback from surveys was positive about the environment. Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. People are being well supported by a stable and qualified staff team who know them well. They are being protected by the recruitment practices. EVIDENCE: The current rota showed that three staff normally work the morning shift and two cover the late afternoon and evenings. At night one worker sleeps in who is on call if needed. Because all four men need one to one staff support to access the community when only two staff are on opportunities for going out are greatly reduced. The rota and diary showed that staffing levels are linked to planned activities, such as swimming, and health appointments. The team includes seven female workers and one male worker. As all the residents are male more male staff on the team would be beneficial. Since the last inspection two care staff have left. There are currently vacancies that are being recruited to. Mrs Jones reported in the AQAA staff shortages over the last year have stretched the team and slowed down improvement plans. Staff induction and core training is managed centrally by the organisation. All new staff are expected to complete the Learning Disability Award Framework and core training such as Food Hygiene, Fire Safety and Moving and Handling. Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 19 All staff hold an NVQ award and some are working towards a higher level. At the last inspection it was reported that the majority of staff hold a First Aid qualification. This provides a good level of cover for the men. Mrs Jones reported in the AQAA that all new staff have five shadow shifts as part of their induction period and that the training programme meets the national minimum standards. She did not provide any details of any specialist training that has been provided or if a training plan was in place for 2008. Discussions with staff highlighted that training about care planning may be helpful. Training on the Mental Capacity Act should also be provided to help staff understand how to record details of decisions that they make on the med’s behalf. Recruitment records are held centrally. A requirement was made at the last inspection, as recruitment checks were not robust enough. Mrs Jones reported in the AQAA that all required checks are now being carried out prior to employment commencing. The care staff on duty did not have access to recruitment information. Following the inspection the manager reported that a checklist of CRB information has been set up in the home. No mention was made of a checklist with the other information required under schedule 4 that was recommended at the last inspection. Two staff on duty were spoken with. Both were established and experienced members of the team. Both seemed to have a good attitude towards their role and they felt that the men were receiving a good quality of care. One said the staff team are flexible and will cover vacancies so that agency staff are not needed. This provides good consistency for the men. They were receiving supervision and attending staff meetings regularly. Feedback in surveys was positive about the staff. One relative said, ‘they look after my nephew to the highest possible standard. They are always very friendly and helpful’. People felt that most staff had the right skills and experience to support the men. Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The people living in the home are benefiting from a well run service. Their health, safety and welfare are being promoted. EVIDENCE: The management arrangements in the Home remain stable. Mrs Jones has been in post for four years and she is supported by a deputy. Mrs Jones has relevant experience and has obtained an NVQ4 in Health and Social Care and the Registered Managers Award. She and the deputy work regularly providing direct care so they keep well informed about people’s care needs and their wellbeing. Systems are in place to allow staff to give feedback through supervision and staff meetings. A company line manager oversees the service and provides Mrs Jones with supervision. Mrs Jones returned the AQAA in the required timefame. The information was very brief and in some areas did not cover all the key standards. It did not clearly report on the recommendations made at the previous inspection and as she was on leave at the time of the Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 21 visit it was not possible to follow up some of these so they have been brought forward. More information will be needed to enable us to carry out an Annual Service Review instead of an inspection. The providers have been carrying out their legal duty to visit the Home each month and report their findings to the directors and the Commission. A new more formal quality assurance system was being introduced at the time of the last inspection. Mrs Jones made no mention of this in the AQAA and did not say if any consultation surveys had been sent out to stakeholders to obtain feedback. She said in the AQAA that staff read and sign all policies and procedures so they are aware of their responsibilities. Information indicated that several of these have not been reviewed for several years, however, following the inspection it was reported that they have been reviewed. In the past Mrs Jones has reported significant events to us. None have been reported since the last inspection. The sample of records seen were being maintained and kept up to date. A sample of people’s financial records showed that appropriate purchases have been made on their behalf such as toiletries and drinks on outings. Staff reported that the deputy checks these records monthly, however there is no evidence of this. This issue was raised at the last inspection. The money tins were being stored securely. The organisation has a representative who takes the lead on Health and Safety matters. This person supports Mrs Jones when needed to write and review risk assessments. Mrs Jones said all routine safety checks such as water temperature and fire equipment testing are diarised so staff do not forget them. Dates provided showed that all equipment had been appropriately serviced. e.g. fire alarm. Hoists may need to be serviced twice a year rather than annually as the AQAA indicates. Mrs Jones should seek advice about this. Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 22 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 2 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 3 25 3 26 4 27 4 28 4 29 4 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 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 4 13 3 14 4 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 1 3 3 3 x Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 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 YA6 YA19 YA12 Good Practice Recommendations Details of the person centred planning meetings should be included in the care plan and agreed actions linked into the goal planning and review processes. Develop the level of daily recording so it includes details of whether people have enjoyed or benefited from the activities they were offered during the day. Implement health action plans. Brought forward. Continue to develop communication systems appropriate to each person. Brought forward. All tablet stocks held in the Home should be included in the records and any auditing process. A competence assessment process should be introduced to Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 24 2. YA7 3. YA20 evidence the manager’s decision to delegate the responsibility to administer medication to new staff. Brought forward. Use a controlled drug register to keep an audit trail of a schedule 3 medication that is used in emergencies. 4 YA34 YA18 Keep a checklist in the home that confirms that satisfactory recruitment checks have been received prior to employment. (Reference Schedule 4 paragraph 6 (d), (e), and (g) of the Care Home Regulations). Brought forward. Try to recruit more male staff to better reflect the people living in the Home. 5 YA35 YA6 Provide training on the Mental Capacity Act 2005 and implement these principles into care planning and recording practices. Fully implement the quality assurance system that includes consultation with stakeholders and link the findings from this to the AQAA that will be required in December 2008. Keep evidence that senior staff are monitoring residents’ financial records regularly. Brought forward. Seek advice to see if hoists should be serviced twice a year rather than annually as the AQAA indicates. 6 YA39 7 YA41 8 YA42 Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Chatsworth Road 94 DS0000024688.V355689.R01.S.doc Version 5.2 Page 26 - 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!