Care Home: Henshaws Society for Blind People

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What the care home does well People were supported by a staff team who had a very good understanding of how to communicate and listen to them and what support and help they needed to stay healthy and well. Staff spent time with people and their interactions was seen to be positive and respectful. It appeared that good relationships had been developed with everyone joking and laughing and getting excited about a trip to see Take That in the evening. People live in a comfortable, clean and homely environment. It has the space and layout to be flexible and to allow people to spend time in communal and private spaces depending on their own preferences. The management and staff team had worked with people and others to find out what was important in their life and to tell others about their story. There was a record called ` about me` that someone could read and this would tell them a lot of useful and interesting information about the person to help understand them and their needs. Recently the staff team had worked with and supported a person to access different specialist healthcare services to make sure that they received the services needed to identify and then provide the right treatment. This was an example of the way that the management and staff team work with a range of different services and professionals to try to make sure that people receive the right support. What has improved since the last inspection? The previous inspection report of June 2006 did not require the service to address any requirements or recommendations. What the care home could do better: The staff team support people with a high level of, at times, complex needs. From talking to staff during the site visit it was clear that they had a very good understanding and knowledge of people and their support needs. Staff held a lot of person centred information and passed on good practice verbally and by example. However, people`s care plans and reviews did not fully reflect their support needs and personal goals and wishes. To make sure that medication which is presented to be given when required (PRN) is given to people correctly staff must have access to clear and detailed administering guidance, so that they know when and why they are giving that medication. A number of recommendations were made for the service to consider in terms of improvements based on current good practice. CARE HOME ADULTS 18-65 Henshaws Society for Blind People 45 Yew Tree Lane Northern Moor Manchester M23 0DU Lead Inspector Steve O`Connor Unannounced Inspection 12th December 2007 12:00 Henshaws Society for Blind People DS0000061522.V351259.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 Henshaws Society for Blind People DS0000061522.V351259.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. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Henshaws Society for Blind People Address 45 Yew Tree Lane Northern Moor Manchester M23 0DU 0161 945 3665 0161 945 4114 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) Henshaws Society for Blind People Miss Kerry Easdale Care Home 6 Category(ies) of Learning disability (0), Physical disability (0), registration, with number Sensory impairment (0) of places Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 29th June 2006 Date of last inspection Brief Description of the Service: Yew Tree Lane is a care home that is owned by Henshaws Society for Blind People. The home provides long-term residential accommodation for up to six (6) service users within the category of Younger Adults (YA). All the young adults must have a visual impairment and may have a learning or physical disability. The premises is a large detached house that has been extensively refurbished to form a care home. Bedroom accommodation is spread over the ground and 1st floors and all bedrooms are en suite. There is also communal bathroom facilities available. It is set in pleasant grounds, which the students have access to. The home is situated in a residential area of Northenden, within easy reach of local amenities. The home has access to the local transport network and is near to the main motorway links in the area. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the home last had a key inspection in June 2006. Additional information that was taken into account included incidents notified to the CSCI and information provided by Henshaws, the organisation that owns and runs the home and other relevant agencies. Before the site visit, we also asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This helps us to determine if the management of the home view the service they provide in the same way that we see the service. During the inspection site visit time was spent talking to people, staff and a senior manager and observing how they work with people. Documents and files relating to people and how the home is run were also seen and a tour of the building was made. Before the site visit people and members of staff were sent surveys asking them to comment on the service. All five people returned surveys that were completed with the support of members of staff. In addition, six staff members returned surveys. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work the CSCI needs to do in the future. What the service does well: People were supported by a staff team who had a very good understanding of how to communicate and listen to them and what support and help they needed to stay healthy and well. Staff spent time with people and their interactions was seen to be positive and respectful. It appeared that good relationships had been developed with everyone joking and laughing and getting excited about a trip to see Take That in the evening. People live in a comfortable, clean and homely environment. It has the space and layout to be flexible and to allow people to spend time in communal and private spaces depending on their own preferences. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 6 The management and staff team had worked with people and others to find out what was important in their life and to tell others about their story. There was a record called ‘ about me’ that someone could read and this would tell them a lot of useful and interesting information about the person to help understand them and their needs. Recently the staff team had worked with and supported a person to access different specialist healthcare services to make sure that they received the services needed to identify and then provide the right treatment. This was an example of the way that the management and staff team work with a range of different services and professionals to try to make sure that people receive the right support. 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. Henshaws Society for Blind People DS0000061522.V351259.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 Henshaws Society for Blind People DS0000061522.V351259.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs were assessed before they come to live at the home. EVIDENCE: All the people who come to live at the home have previously attended the Henshaws (the registered provider) residential college. The management and staff team have access to assessment information and support guidance developed whilst the person attended college. In addition, staff would visit the person whilst they were still at college and spend a few days with them assessing their needs. Part of the admission process would also include the person visiting the home on a number of occasions so that they could find out about the service and issues of compatibility could be looked at. The decision whether to offer a person a place at the home would be made by the management team after consultation with staff and other relevant people. It is recommended that information gained by the management and staff team through the admission process be recorded and evidenced as part of the pre-admission assessment process. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 9 Placements at the home were purchased through local authority social services. At the time of the site visit there was no evidence of community care or care management assessment information from the purchasing local authority. It is recommended that relevant and appropriate assessment information is gained from the purchasing organisation prior to deciding whether to offer a person a placement at the home. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to be active in choices and decisions about their lives. The support people receive to help them achieve this was not fully evidenced. EVIDENCE: A sample of people’s files were assessed in relation to the care planning and identifying of people’s needs. Staff and management develop, with people, an ‘about me’ document. This explained to the reader the important things in a person’s life and the support that they need. It contained information about significant events and people and personal details about what people like and do not like. In addition, there were records of people’s needs around personal care, mobility, domestic support and behavioural issues. These set out in detail how to support people in these areas. It was found that the majority of these had not been dated, did not identify who was involved in developing the record or have any signatures of relevant people to confirm their involvement. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 11 From discussions with staff and observing the way they worked with people it was found that they had an in-depth knowledge and understanding of people’s needs. However, the care planning process and documentation did not fully reflect people’s person centred needs or the way that staff supported people and the progress that they had made. There was very little evidence that people’s changing needs and support had been reviewed and updated to reflect people’s progress. The Care Planning and Review process and documentation must clearly reflect the person centred needs and goals of people and the actual support the staff team provide to meet those needs and goals. During the time spent on the site visit it was observed that staff were talking to people in a very positive way. Plans and activities where being discussed with a number of people going out to a concert that evening which they had chosen. People were included in conversations and staff made sure that everyone was included. Any restrictions on people’s choices and decision making was based on individual risk assessments and the management were aware of the Mental Capacity Act 2005 and the implications for issues such as decisions around people’s health and finances. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported to have a lifestyle based on individual needs and routines. Relationships with family and friends were encouraged and supported where appropriate. People’s choice of meals was nutritious and based on what they like. EVIDENCE: The staff team worked with people to identify their personal interests and what activities they enjoyed taking part in. Samples of care plans were seen that identified this information. People were supported to participate in college courses, social and leisure clubs and events. At the time of the site visit several people and staff were going to a major concert event in Manchester. People’s religious and cultural needs were being supported by the staff team. From discussions with staff and observation of how they worked with people it was found that staff members had a very good understanding of what people Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 13 liked to participate in. However, the information in people’s care plans did not fully reflect this awareness. It was also found that many of the activities that people tended to be specifically for people with a learning disability, such as specialist college courses, social nights and events. It is recommended that the management and staff team apply a more person centred approach to identifying and supporting people’s individual cultural, social, leisure and community needs. The management and staff team supported people to maintain family relationships based on their individual needs and family circumstances. The staff on duty at the site visit demonstrated a good awareness of the different methods of communication used by people and their approach was observed to be respectful. People’s routines would be based on the individual’s activities and interests. The staff team were of sufficient size to provide, at times, almost a 1:1 level of support for people to support them in an individual person centred routine. The issue of making people’s support more person centred has been raised in the Individual Needs and Choices section. People’s nutritional needs had been identified and where required, specialist health input had been gained to provide clear and detailed nutritional guidance. People were asked about what meals they enjoy and were involved in the development of menus and in shopping for food. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were having their personal and healthcare needs met by the staff team. Arrangements were in place for safeguarding people’s health and welfare. EVIDENCE: People’s personal care needs were clearly identified in the care planning and the information was clear and detailed and reflected how people wanted to be supported. Healthcare needs were also clearly identified and an example was seen where a person had been supported to access specialist health providers and had received guidance and relevant training in supporting these health needs. People were supported to access general healthcare services such as dentists, GPs and chiropodists. People’s mobility needs had been clearly identified and there was clear guidance in how staff were to support people in a safe way. Equipment and aids and adaptations were in place to support people’s health and mobility needs. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 15 The medication administration system was assessed. All deliveries and returns of medication had been clearly recorded. The Medication Administration Record (MAR) had been used accurately with all administered medication clearly signed for. Several people were prescribed with medication ‘as required’ (PRN) but there was no written administering guidance to inform staff when to give the relevant medication. All PRN medication must have clear and detailed administering guidance. Staff were able to describe how they check that the MAR sheet had been recorded correctly and that the right amount of medication had been administered. However, there was no formal recorded audit to show clearly that people had received all the medication they needed. A recommendation was made. It was found that some people had a lot of prescribed creams and medication that they no longer used. It is recommended that the MAR sheet be reviewed with the pharmacist to ensure that only people’s current medication was recorded. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff were aware of the procedures and practices to follow to try to maintain people’s safety and wellbeing. EVIDENCE: People did have access to a formal complaint policy and procedure from the main organisation, Henshaws. There had been no formal complaints made since the previous inspection report in June 2006. The issue of how people can make complaints or raise their concerns was raised with the staff on duty. The staff team support people with a visual impairment and additional learning disabilities and were knowledgeable regarding how people communicated their needs. However, it is recommended that the complaint information made available to people is in a style and format that is relevant to the needs of the people using the service. It is also recommended that people’s informal concerns and worries that require the staff team to take some action to change things are clearly recorded. Several staff were asked about the actions they would take in relation to an allegation/incident of abuse. Those asked were able to explain clearly the steps they would follow in informing the manager of their concerns and observations. Staff confirmed that they had attended training in the Protection of Vulnerable Adults (POVA) and described what they had learnt. Staff operate a policy of non-physical intervention where people’s behaviour may be challenging and could cause harm. Staff spoken to were able to Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 17 describe the challenging behaviour training they had attended and how they would follow the risk assessment guidance to support people. Staff had access to clear procedures for the management and recording of people’s finances. The finance records were sampled and found that they were accurate and referred to an invoice for each transaction. Cash balances were checked by staff on a daily basis. No one had their own bank account as either family members, who were the appointees, or an Enduring Power of Attorney managed people’s benefits and finances. People’s personal monies was sent to Henshaws and staff team then supported people to manage their monies. If it was felt appropriate to spend larger amounts of people’s money on personal items then families had be consulted and asked for the money. An example was given where a request for additional monies was not agreed by the family. The management were aware of the implications of the Mental Capacity Act 2005 and it is recommended that a process is in place where the relevant advocate can be accessed at times where the person’s opinion/choices needs to be upheld. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable and safe environment that meets their needs. EVIDENCE: The premises provide an open environment for people to easily access different communal and private areas. The premises contained the necessary aids, adaptations and equipment required to meet people’s needs. The home was clean and well maintained with a modern contemporary look with suitable furniture and fittings. Strong colours were used to distinguish key areas such as entrances and passages to aid people with a visual impairment. Some areas of wallpaper and paintwork were starting to show signs of wear and tear and it is recommended that a programme of redecoration is developed for the whole building. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 19 Several people require hands on intimate personal care. Staff on duty were asked about the procedures to follow to minimise the risk of cross infection. Protective equipment such as disposable gloves and aprons were used and there is a separate disposal system for risk items. The only part of the procedures that staff were not totally clear about was in the need for ongoing hand-washing. It is recommended that all staff are made aware and understand the importance of maintaining a safe hand-washing regime. The laundry facilities were suitable to meet people’s needs. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported by a staff team with the numbers and skills to meet their needs. EVIDENCE: The staff team consisted of the registered manager, a senior support worker and 10 support staff working various hours. In addition, when required agency staff were used to cover shifts. The staff rotas were seen and it was found that when agency staff were used they were well known to people. During the day and into the late evening at least four staff were on duty at all times. At certain hours during the day at least six staff were on duty and available to support the five people living at the home. The staffing levels were very flexible and could be changed to provide additional cover at times when social/leisure events were planned. It is recommended that the effective use of staff be reviewed to provide a person centred support package for each individual based on their needs and personal goals. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 21 Through talking to and observing how staff work with people it was shown that they had the knowledge, skills and values to support people in a positive way. All but one of the staff team had gained the NVQ Level 3 in care. Staff were employed through the main organisation Henshaws who have a clear recruitment policy and procedure. A number of staff had recently been appointed and all the required checks and documentation had been gained prior to them starting work. Staff follow an Induction Programme of core training and awareness that includes Health and Safety, Moving and Handling, First Aid, Basic Food Hygiene, Medication and Adult Protection. Staff records were seen where they had attended various training events and nominations for further core training. At the time of the inspection the main organisation, Henshaws, did not provide any training programme and the manager stated that training events for staff were accessed through a local authority programme of free training for private care providers. From discussions with the manager and staff team it was shown that they do undertake ongoing awareness raising within the home but this had not been recorded as training. It was also unclear from the information seen whether the Induction programme was based on the Skills for Care Induction Modules. It is recommended that the Induction Programme be reviewed to make sure that it meets the Skills for Care Induction Modules. It is recommended that a system be implemented that assesses the competence of how staff implement the knowledge and skills learnt through training events. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from an effective management team and procedures and practices maintain their health and safety. EVIDENCE: The registered manager had been in post as manager since March 2007. previously they had managerial experience in other social care settings supporting vulnerable people with high levels of need. The manager had completed the Registered Managers Award in 2006 and was also a qualified NVQ assessor. From discussions with the manager it was clear that they were aware of the issues that needed improving in the service and had already started planning to make those changes. The management of the service was also supported Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 23 through a senior support worker with key roles and responsibilities and through senior management. At the time of the site visit a senior manager was visiting the service as part of their responsibilities under the Care Homes Regulations. At the time of the site visit the service had no formal quality assurance system. Staff had the opportunity to meet together on a regular basis to exchange views and information and the manager was planning to hold residents meetings. It is recommended that a system of quality assurance be implemented that gathers people’s views on the quality of the service and is used to develop a clear plan for the further improvement of the service. The home provided evidence, through its AQAA, that equipment and services had been serviced and were safe to use. The fire log showed that the required visual checks were being made on fire equipment. Policies and procedures relating to health and safety were in place such as RIDDOR, COSHH and temperatures of hot water sources, fridge and freezers were being maintained. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 (1) (2) (b) Requirement The Care Planning and Review process and documentation must clearly reflect the person centred needs and goals of people and the actual support the staff team provide to meet those needs and goals. To make sure that PRN medication is given to people correctly staff must have access to clear and detailed administering guidance. Timescale for action 30/03/08 2 YA20 13(2) 30/01/08 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 YA2 Good Practice Recommendations It is recommended that information gained by the management and staff team through the admission process be recorded and evidenced as part of the preadmission assessment process. It is recommended that relevant and appropriate Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 26 assessment information is gained from the purchasing organisation prior to deciding whether to offer a person a placement at the home. 2 3 YA6 YA13 YA12 It is recommended that all care planning and other relevant documentation be dated, clearly identify who was involved and contain the signatures of relevant people. It is recommended that the management and staff team apply a more person centred approach to identifying and supporting people’s individual cultural, social, leisure and community needs. To make sure that people receive the correct medication it is recommended that a formal recorded audit is undertaken during the medication cycle. It is recommended that the MAR sheet be reviewed with the pharmacist to ensure that only people’s current medication is recorded. It is recommended that the complaint information made available to people is in a style and format that was relevant and able to be understood by the people using the service. It is also recommended that people’s informal concerns and worries that require the staff team to take some action to change things are clearly recorded. 6 7 8 YA23 YA24 YA30 It is recommended that a process is in place where the relevant advocate can be accessed at times where the person’s opinion/choices needs to be upheld. It is recommended that a programme of redecoration is developed for the whole building. It is recommended that all staff are made aware and understand the importance of maintaining a safe hand washing regime. It is recommended that the effective use of staff be reviewed to provide a person centred support package for each individual based on their needs and personal goals. It is recommended that the Induction Programme is reviewed to make sure that it meets the Skills for Care Induction Modules. It is recommended that a system is implemented that assesses the competence of how staff implement the Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 27 4 YA20 5 YA22 9 YA33 10 YA35 11 YA37 knowledge and skills learnt through training events. It is recommended that a system of quality assurance is implemented that gathers people’s views on the quality of the service and was used to develop a clear plan for the further improvement of the service. Henshaws Society for Blind People DS0000061522.V351259.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Henshaws Society for Blind People DS0000061522.V351259.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. 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