Care Home: Burnby Lane 23

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What the care home does well People`s differing needs are assessed before they receive a service of care and support in the home, and they are provided with some information about the home and staff in order to decide whether or not their needs can be met there. People have their needs and changing needs recorded in a plan of care, which takes into consideration their individual differences. They are encouraged to make their own decisions about daily life, as much as possible, which may involve taking risks in order to achieve independence. However, these risks are reduced where possible. People take part in appropriate community based activities and pastimes within the home or in the community, they enjoy relationships of their choosing with good advice coming from staff, and have their rights and responsibilities as citizens upheld wherever possible. Support workers said people enjoy shopping, going to the pub or for a meal, helping with basic household chores, going to centre, and listening to music and watching television and DVDs. Peoples` rights are respected and support workers always try to encourage their involvement in the community or advocate for them when necessary. People also enjoy a variety of meals and assist in the provision of and preparation of food wherever possible. Support workers say they provide the help and support with personal care and with physical and emotional health needs in a way that suits the people living in the home. This is something that has been tried and tested in order to achieve a successful outcome for the people living there. People are well protected by the home`s systems for controlling and administering medication. They have their views listened to and feel confident they can make representations or concerns and complaints known to the staff or the manager, in their own individual way. People live homely environment that is clean and suits their preferences. Competent and qualified support workers provide support to people in their daily lives. Support workers are well-recruited so safe workers care for people that live in the home. The home manager is well trained and experienced and provides consistent leadership. There is a good quality assurance system in place, which self-monitors the service provided. The health, safety and welfare of people and staff are well promoted and protected. What has improved since the last inspection? The home manager now makes the assurance that all prospective people will have a full assessment of needs undertaken before they are provided with a service of care in the home. Peoples` care plans are now being kept up to date. Support workers have had safeguarding adult`s training, and any incident that warrants it is referred to the safeguarding adult`s team. What the care home could do better: The service could make sure care plans are used more effectively as a working tool to assist people to maintain independence and to achieve fulfilment. The service could also make sure the manager is allocated more time for managerial duties so that records can be better maintained, thereby showing a good account of the care and support planned and provided. The service could also increase the number of weekly-allocated care hours, so that people have their needs met and the manager undertakes less support of people and support workers undertake more support, thereby enabling people to have more time spent with them to live a fulfilling lifestyle. CARE HOME ADULTS 18-65 Burnby Lane 23 23 Burnby Lane Pocklington York East Riding Of Yorks YO42 2QB Lead Inspector Janet Lamb Key Unannounced Inspection 16th October 2007 09:30 DS0000019634.V353118.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 DS0000019634.V353118.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. DS0000019634.V353118.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burnby Lane 23 Address 23 Burnby Lane Pocklington York East Riding Of Yorks YO42 2QB 01759 302602 F/P01759 302602 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) www.mencap.org.uk Royal Mencap Society Mrs Paulette Marie Gill Care Home 4 Category(ies) of Learning disability (4) registration, with number of places DS0000019634.V353118.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2006 Brief Description of the Service: 23 Burnby Lane, Pocklington is a five bedroom detached home that is registered for four adults with a learning disability. The property is in keeping with the local community and is situated in a country lane a few minutes walk from the centre of Pocklington. The Royal Mencap Society provides a service of care in a property that is owned by Dimensions. The accommodation is situated on two floors. Access to the first floor is by stairs. All bedrooms are single rooms and residents are encouraged to personalise and furnish their own rooms. There is a comfortable lounge/dining area with television and CD player. An enclosed garden is situated to the rear of the house. The registered manager is Mrs Paulette Gill. On the 16th October 2007 the fees for the home ranged from £787.86 to £1009.23. DS0000019634.V353118.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection of 23 Burnby Lane has taken place over a period of time and involved sending a request for information to the home in early September 2007 concerning people and their family members, as well as staff and details of the home’s policies, procedures and practices. The Commission received the requested information at the beginning of October 2007 and questionnaires were then issued to all people and their relatives, their GP and any other health care professional with an interest in their care and to social service departments commissioning their care. This information obtained from surveys and information already known from having had contact with the home over the last few months, was used to suggest what it must be like living there. A site visit was made to the home on 16th October 2007 to test these suggestions, and to interview people, staff, visitors and the home manager, if available. Some documents were viewed with and without permission from those people they concerned, and some records were also looked at. The communal areas of the home were viewed. A total of two staff were interviewed and two people were observed during the site visit to seek information. What was said was checked against the information obtained through questionnaires and details already known because of previous information gathering and contact with the home. A telephone conversation was held with the home manager two days after the site visit to clarify some of the information. Judgments were made using the information to say what it is like living in the home. What the service does well: People’s differing needs are assessed before they receive a service of care and support in the home, and they are provided with some information about the home and staff in order to decide whether or not their needs can be met there. People have their needs and changing needs recorded in a plan of care, which takes into consideration their individual differences. They are encouraged to make their own decisions about daily life, as much as possible, which may involve taking risks in order to achieve independence. However, these risks are reduced where possible. People take part in appropriate community based activities and pastimes within the home or in the community, they enjoy relationships of their choosing with good advice coming from staff, and have their rights and responsibilities as citizens upheld wherever possible. Support workers said people enjoy DS0000019634.V353118.R01.S.doc Version 5.2 Page 6 shopping, going to the pub or for a meal, helping with basic household chores, going to centre, and listening to music and watching television and DVDs. Peoples’ rights are respected and support workers always try to encourage their involvement in the community or advocate for them when necessary. People also enjoy a variety of meals and assist in the provision of and preparation of food wherever possible. Support workers say they provide the help and support with personal care and with physical and emotional health needs in a way that suits the people living in the home. This is something that has been tried and tested in order to achieve a successful outcome for the people living there. People are well protected by the home’s systems for controlling and administering medication. They have their views listened to and feel confident they can make representations or concerns and complaints known to the staff or the manager, in their own individual way. People live homely environment that is clean and suits their preferences. Competent and qualified support workers provide support to people in their daily lives. Support workers are well-recruited so safe workers care for people that live in the home. The home manager is well trained and experienced and provides consistent leadership. There is a good quality assurance system in place, which self-monitors the service provided. The health, safety and welfare of people and staff are well promoted and protected. What has improved since the last inspection? The home manager now makes the assurance that all prospective people will have a full assessment of needs undertaken before they are provided with a service of care in the home. Peoples’ care plans are now being kept up to date. Support workers have had safeguarding adult’s training, and any incident that warrants it is referred to the safeguarding adult’s team. DS0000019634.V353118.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. DS0000019634.V353118.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 DS0000019634.V353118.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): 2 only. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People have their needs well assessed so they are confident their needs will be met. They receive sufficient written/pictorial information so they can decide if the home is the right place for them. EVIDENCE: Two people were asked if they would give permission for their files and records to be viewed, but neither were fully able to give comments on what was being asked of them. A decision was made to view their documentation. The two files seen did not contain copies of either an original or an updated assessment document, from either the placing authority or Mencap. This confirmed last year’s findings, but a conversation with the manager two days after the site visit and receipt of documentary evidence via fax provided the evidence to declare that people are assessed and information is recorded. Of the four people living in the home, two have no assessment documents because they have been resident for nearly 20 years, the other two have and this was the evidence faxed to CSCI. DS0000019634.V353118.R01.S.doc Version 5.2 Page 10 The home does have copies of the most current ‘statement of purpose’ and ‘service user guide’ though and these were seen. They were only in written format and could do to be updated in picture form. People using the service and their relatives therefore have some information on what to expect and how their care will be provided and they will be supported. DS0000019634.V353118.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. Peoples who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People have good care plans that enable them to be independent and to make choices, and people enjoy making their own decisions in life, with good risk assessments being put into place where necessary, so they are confident their lifestyles meet their expectations. EVIDENCE: Two care plans were viewed, but without peoples full consent. Care plans include information on all aspects of personal care given and support provided, and are underpinned by risk assessment documents, which allow people to take risks if necessary. There are also health care plans in place, which are new to the service and which include health care needs as well as personal needs. These are still in the process of being completed. People’s care and health care plans are now being kept up-to-date with regular reviewing of DS0000019634.V353118.R01.S.doc Version 5.2 Page 12 needs and a more detailed annual review of the documentation involving the attendance at a review meeting. Evidence is maintained in the form of review dates and minutes of the meeting, as well as in the form of internal reviewing of care plans by the support workers and management. People continue to make choices about daily life and decisions where possible and the staff uphold Mencap’s philosophy to encourage independence in all things. People were observed making basic decisions to come and go from the room, or to refuse or accept the offer of a drink etc. One person wandered up on the stairs several times, while another flicked through magazines and sorted some of them for the rubbish. Risks are kept to a minimum and people are protected from harm because of the safeguards in place to reduce risks. For instance the doors are kept bolted while people are home, as two people would easily wander from the home and be in serious danger of injury from traffic. One person is able to let himself out of the home, but leaves the door open and does not understand the risk for the others. Therefore all people going out on activities etc. are fully accompanied. All risk assessments are recorded and reviewed. DS0000019634.V353118.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 the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People lead and enjoy appropriate inclusive, healthy and fulfilling lifestyles in the home and within their local community, so their quality of life is good. EVIDENCE: Discussion with support workers, observation of people in the home and viewing of diary notes reveals individuals have different activities and pastimes to pursue. Two went out to day services in the town and in York, while the other two remained at home. Usual activities include shopping, walking, swimming, music and day services, with holidays and outings taking place according to individual arrangements. Some also have connections with the local church, patronise the local pub and use the local surgery. DS0000019634.V353118.R01.S.doc Version 5.2 Page 14 Keeping in touch with family members is important to people and this is facilitated well by the support workers. Transport is available to all four people living in the home, as there are three ‘motability’ vehicles belonging to them. Support workers can be nominated drivers providing they are included on insurances and have all the legal documents etc. to drive. Mencap checks these regularly. There are no people with paid jobs in the home. Links with the community are satisfactorily maintained and people use the local area and its facilities well. People mostly determine their daily routines themselves. Privacy is respected and support workers only enter rooms with permission or to undertake cleaning chores when the room is empty. People have access to the rear garden at any time, but are discouraged from leaving the house by the front door. Sometimes people will assist in basic household chores, but this is only with supervision and guidance. Meal times are usually set, but fit around people’s activities. There are three meals a day, plus supper, and all food consumed is recorded on an individual basis. People’s likes are recorded and food provision is usually according to these likes. All activities and happenings in relation to people’s lifestyles are according to their choice, recorded in care plans and reviewed as needs change. DS0000019634.V353118.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 the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People receive good assistance and support to maintain their personal and health care, so they are confident their needs will be met. They do not experience the opportunity to self-medicate, because of risk, but their levels of choice and independence are good in other areas. Medication systems are good in respect of storage and recording so people’s needs are met. EVIDENCE: Discussion with support workers, observation of people in the home and viewing of health care plans reveals people are provided with a health care plan that shows their individual assessed needs and how they should be met. All medical and health care needs are recorded in plans and support is given to ensure people lead healthy lifestyles. Any specialist requirement or health need is discussed with professionals and treatment is provided as necessary. DS0000019634.V353118.R01.S.doc Version 5.2 Page 16 People may be the subject of a ‘best interest’ meeting, if their needs are such that they are unable to make their own informed choice about health care. All of these strategies are recorded and any recommendations made are only made by a multi-disciplinary team of carers and professionals. Records in files also show appointments with GPs, as hospital outpatients and for such as dental, optical and chiropody needs etc. Medication is only administered by the manager or support staff and only after appropriate training. There are systems in place that follow policy, procedures and safe working practices, and which ensure support workers administer drugs safely and correctly. There is a medication ‘handover’ between each shift, which involves the checking of drugs in the home and recording of the accuracy of the stock. Support workers sign to say they are accepting a correct stock level and that everything is as it should be with the handling of medicines. Storage of medicines is in the kitchen of the home, as would be the case in any domestic dwelling, but it is locked away and handled in line with the requirements of the standard and stated legislation. No one selfmedicates in the home at the moment. Medication administration record sheets seen are satisfactorily completed and maintained. DS0000019634.V353118.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 the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People are confident their concerns and complaints are listened to and acted on, and they are safeguarded against harm or injury, so people are properly protected. EVIDENCE: Discussion with support workers and viewing of documents in relation to protection and representation show that people are well protected from harm or abuse and have their concerns or complaints listened to. There are complaint and protection policies and procedures in place and support workers are trained in safeguarding adult’s issues. Evidence is held in the form of staff training records. There have been no complaints or adult protection referrals in the last 12 months. Records are held of any incident, accident or behavioural situation within the home and in individuals’ personal files for maintaining confidentiality. People are encouraged to join in with meetings on a regular basis and support workers will represent a person unable to verbalise their dissatisfactions as expressed in prior behaviour observed by support workers. Family members are also encouraged to express what they understand to be the views or feelings of their relative living in the home. Mencap has a wide network of DS0000019634.V353118.R01.S.doc Version 5.2 Page 18 social care workers and professionals to call upon to seek information following any allegation or complaint, and the organisation generally works well with the local authorities it liaises with. DS0000019634.V353118.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 the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People enjoy a clean, comfortable and homely environment, in a home that is suited to it stated purpose, so they are confident their need for a safe and secure place to live is being met. EVIDENCE: Discussion with support workers, observation of people in their living environment and viewing of the communal areas of the home shows that the environment is satisfactorily maintained, is safe, clean and comfortable. It is only a mile or so from the centre of Pocklington and has easy access to bus routes and local shops, as well as the rugby union football ground. The home is suited to its stated purpose of providing a homely family care setting, where people can be individuals. The house is appropriately DS0000019634.V353118.R01.S.doc Version 5.2 Page 20 maintained, although internal decoration in the lounge and some refurbishment is now due. The lounge carpet is very dated, though it is still in a reasonable condition. The lounge exit to the rear garden would benefit an upgrade also. People’s rooms were not viewed, but the entrance hall and stairs were seen and noted as having been recently redecorated. The kitchen is domestic in style and fittings and is suitable. People’s views could not be obtained, but they were observed to be relaxed and comfortable and pleased themselves where they sat or wandered. The home has been registered for some years and has been the home to two people for almost 20 years, and so as a pre-existing home it provides the same private and communal living space as it did before the Care Standards Act (2000) came into force. There are no facilities for people with a physical disability except for ramps to the front and rear entrances, and one small bath seat for easier transfer into the bath. There is a ground floor toilet. DS0000019634.V353118.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 the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People who use the service benefit from appropriately recruited and well-trained staff, but not always in sufficient numbers to meet their needs, so they are confident their lifestyles will be respected. EVIDENCE: Discussion with support workers and viewing of the home’s rosters reveal that the home is providing sufficient staff with the right training to meet the needs of people living there. There are two support workers on duty most of the day with one on sleeping night duty during the night. There are also some days when one support worker may be lone working with two people in the home that have not gone out to day services. This is only for short periods and for the two less active people that live there. The Residential Staffing Forum calculations require a DS0000019634.V353118.R01.S.doc Version 5.2 Page 22 minimum of 261.95 for three high and one medium dependency people. The home’s rosters show there are 242.5 hours per week, including the sleep in hours. The home is not meeting the forum recommendations and could do to increase its staffing in order to meet people’s needs and to offer people a better quality of life if they are to undertake more activities and outings. Support workers undertake induction, foundation and any specialist training according to people’s needs. They complete such courses as are related to the people’s conditions and personal needs, which include epilepsy, invasive medication administration and dementia etc. A list of support worker training is maintained at the home within staffing files. At the last inspection there was a requirement to make sure all support workers are aware of the safeguarding adult’s systems. Information supplied by the home for this inspection shows all of the seven support workers working there have completed either protection of vulnerable adult’s training or safeguarding adult’s awareness training within the last two years. Support workers’ recruitment files could not be seen on the day of the site visit because of being locked away and only the manager having access to these. However, discussion with support workers and the fact all recruitment issues were satisfactorily checked at the last key inspection enables us to determine that recruitment and selection procedures are well followed and practices are robust to enable effective recruitment of safe staff. Information also received from discussion with support workers and from the list of training held in the home shows five from seven workers have the required qualifications at level two or three. DS0000019634.V353118.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 the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. People who use the service benefit from having a registered manager that is competent and is maintaining consistency within the service. She is completing the required qualification. People have a quality assurance system in use that is effective and they enjoy good protection from harm under the home’s health and safety measures in place and the practices carried out, so people are confident their health, safety and welfare are well promoted and protected. EVIDENCE: DS0000019634.V353118.R01.S.doc Version 5.2 Page 24 Discussion with support workers and viewing of maintenance certificates and records reveals the home is run and managed with the health safety and welfare of people and staff being promoted and protected. The manager is completing the required management qualification at level four and runs the home with an open door policy. She has some responsibility to complete hands-on tasks and is often the second support worker on duty. However, a recommendation to make sure she spends more time on managerial tasks was made at the last inspection. Discussion with the manager reveals there has been little change to this in the last twelve months. Menacp must address the situation and in view of the fact that the service is only just meeting the recommended Residential Staffing Forum figures, as reported in the section on ‘staffing,’ should seriously consider employing another support worker to increase the care hours to people living in the home and to provide the manager with more time to undertake her managerial role. There is a quality assurance system in use, which includes surveying people and their relatives, holding meetings for support workers and seeking opinions at any opportunity. The manager produces outcomes to be achieved after records have been maintained. None of the quality assurance system paperwork etc. could be viewed on the day of the site visit, but discussion with the manager afterwards was sufficient to determine there is a fairly effective system in place. Areas that were sampled as part of the checks on health, safety and welfare of people and support workers were fire safety, gas safety, cleaning substance usage, legionella testing, and checks on the hot water outlets. The fire system was last maintained in June 2007, weekly equipment checks are held on the lights, alarms etc. and recorded, and monthly fire drills are carried out and also recorded. The home meets the requirements of the local fire department. A landlord’s gas safety certificate is available and shows the last check undertaken was in September 2007. All cleaning materials used in the home have individual risk assessments for their use and support workers ensure they are safely stored away from the reach of people at risk of harm from them. There are also Control of Substances Hazardous to Health information leaflets available with instructions on the dilution of substances. Support workers were seen to be working safely with materials. The home has undertaken a safety check on the hot water storage tank and has had a sample of water taken for testing, but the result is not yet available. Support workers do carry out hot water outlet checks on a periodic basis and keep records of these. DS0000019634.V353118.R01.S.doc Version 5.2 Page 25 There are accident records held for people on an individual basis in the form of incident records, but there has been none completed for a while. Four of the seven support workers have completed emergency first aid training in the last two years. The home tries to ensure a sensible approach is used in the promotion and protection of people and support workers’ health, safety and welfare. DS0000019634.V353118.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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X DS0000019634.V353118.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. 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. 2. Refer to Standard YA6 YA33 Good Practice Recommendations It is recommended that care plans be used more effectively as a working tool to assist people to maintain independence and to achieve fulfilment. It is recommended that the provider increases the number of care hours per week to that of the Residential Staffing Forum recommendation, to enable the manager to have more time to undertake managerial chores and to enable people to have more time spent with them so their needs are met and so they achieve greater fulfilment and satisfaction in their daily lives. It is recommended that the manager be allocated more time for managerial duties so that records can be better maintained, thereby showing a good account of the care and support planned and provided. Little improvement has been made in this area since the last inspection. 3. YA41 DS0000019634.V353118.R01.S.doc Version 5.2 Page 28 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 DS0000019634.V353118.R01.S.doc Version 5.2 Page 29 - 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. 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