Care Home: Lister Project

What the care home does well All of the staff spoken with displayed a commitment to the service, and to supporting people. Staff and people living at the home were positive about the acting manager, and felt that they were listened to. The interactions observed between people living at the home and staff appeared respectful and supportive. In their questionnaires, and in direct conversation, people said "The staff are very caring, they help me" "Staff listen to me when I have worries" "I can talk to my key worker" In their questionnaires, 3 of 4 staff said they were "Always" given enough information about the needs of people. One staff said "Usually". All 4 staff said that they "Regularly" met with their manager for support. Comments from questionnaires included; "I receive regular supervision and excellent feedback to provide me with structure and support" "Improved tenant participation" "Excellent additional training provided" In their questionnaires, health professionals said; "Good liaison and communication with others around the clients difficulties" "There are some very excellent staff who have a good understanding of the client we both work with, who is very complex" "Works as a team, talks to clients as individuals. Tries to make people happy" What has improved since the last inspection? What the care home could do better: Daily records should include more detail so that full information is available to staff. People should be further consulted about the menu so that their choices can be fully taken into account. Refresher training on safe medication administration must be provided to staff to make sure safe procedures are followed and people are kept safe. The written complaints procedure must inform people that they can contact the Commission for Social Care Inspection (CSCI) at any stage, and include contact details should people wish to do so. Some carpets and furniture must be cleaned or replaced so that a pleasant living environment is provided. Efforts must continue to recruit to domestic and cooks vacancies so that Residential Mental Health Workers (RMHW) are free to concentrate on people living at the home. All staff must participate in a fire drill at appropriate frequencies so that they are aware of the action to take in an emergency. A system to monitor staff fire drills should be introduced to assist in their delivery. CARE HOME ADULTS 18-65 Lister Project 2a Basegreen Road Sheffield South Yorkshire S12 3FH Lead Inspector Janis Robinson Key Unannounced Inspection 3rd September 2008 9:00 Lister Project DS0000002981.V371268.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 Lister Project DS0000002981.V371268.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. Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lister Project Address 2a Basegreen Road Sheffield South Yorkshire S12 3FH 0114 249 0553 0114 249 0950 j.carr@syha.co.uk www.syha.co.uk South Yorkshire Housing Association 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) Vacant Care Home 25 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (25), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (5) Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 25 MD mental disorder of which 9 can be used for people with an additional PD (physical disability). This registration includes 5 places at 95 Lister Avenue, Sheffield S12 3FQ; 7 places at 2A Basegreen Road, Sheffield, S12 3FH; 4 places at 2B Basegreen Road, Sheffield S12 3FH; 4 places at 2C Basegreen Road, Sheffield S12 3FH; & 5 places at 2D Basegreen Road, Sheffield S12 3FH. Four specific service users over the age of 65 years named on variation 15.08.05, may reside at the home. 7th September 2006 3. Date of last inspection Brief Description of the Service: The Lister Project provides personal care and accommodation for up to twentyfive people who have mental health problems. The project consists of five adjacent houses, each accommodating up to five people. An external pathway links the houses. To the rear of the houses is an enclosed communal garden, which is provided with seating. Each of the houses is provided with a communal lounge, dining room, kitchen, showers and bathrooms. All of the bedrooms are single. A central kitchen provides the main meals for each house. The home is based in a residential area of Sheffield close to shops and public transport. South Yorkshire Housing Association owns the home. Current fees are £269.00 per week. Information about the home, in the form of a service user guide, and inspection reports are available by request from the home. Lister Project DS0000002981.V371268.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 that the people who use this service experience good quality outcomes. This was an unannounced key inspection carried out by Janis Robinson regulation inspector. Since the last inspection the registered manager had been promoted within the organisation. Kathryn Rochford, permanent deputy manager, was filling the vacancy until a permanent manager was recruited. A site visit took place between the hours of 9.00 am and 4:00 pm on the 3rd of September 2008. Kathryn Rochford, the acting manager, was present during the visit. Prior to the visit the acting manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires, regarding the quality of the care and support provided, were sent to people living in the home, care staff and any professionals involved in peoples care. The Commission for Social Care Inspection (CSCI) received two questionnaires from people using the service, four from staff and two from health professionals. Comments and feedback from these have been included in this report. On the day of the site visit staff were observed interacting with people that live in the home. Opportunity was taken to make a partial tour of the premises, inspect a sample of care records and records relating to the running of the home. Three staff and eight people living at the home were spoken with. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last inspection in September 2006. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home and staff for their time and co-operation throughout the inspection process. Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? A Tenants Action Group (TAG) has been set up to enable people to participate and plan activities. Smoking areas have been relocated and extractor fans provided to create some smoke free environments for people. Parts of the home had been redecorated to provide pleasant living space. The fire alarm system had been updated so that a more efficient means of detecting fire was in place. Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 7 Staff had received some specialist training to improve their skills. Staff files contained all of the relevant information to ensure safe procedures were followed. People’s views had been obtained as part of the homes quality assurance, so that people felt listened to. In questionnaires, health professionals said; “In the past have over consulted for irrelevant matters, but this has greatly improved” “In the past I have felt that clients were missing out on one to one support (emotional, problem solving) and social activities, but this is improving. When asked if the care service supports individuals to live the life they chose, one health professional said “This has greatly improved – people are being encouraged to go out more, be more social” What they could do better: Daily records should include more detail so that full information is available to staff. People should be further consulted about the menu so that their choices can be fully taken into account. Refresher training on safe medication administration must be provided to staff to make sure safe procedures are followed and people are kept safe. The written complaints procedure must inform people that they can contact the Commission for Social Care Inspection (CSCI) at any stage, and include contact details should people wish to do so. Some carpets and furniture must be cleaned or replaced so that a pleasant living environment is provided. Efforts must continue to recruit to domestic and cooks vacancies so that Residential Mental Health Workers (RMHW) are free to concentrate on people living at the home. All staff must participate in a fire drill at appropriate frequencies so that they are aware of the action to take in an emergency. A system to monitor staff fire drills should be introduced to assist in their delivery. Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 8 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. Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Pre admission assessments and visits to the home were undertaken to make sure peoples needs could be met before they decided to move in. EVIDENCE: Three peoples support plans were examined. Each contained copies of assessments undertaken prior to admission. The assessments were comprehensive, and contained information obtained from other relevant professionals, such as psychiatrists and social workers. Sufficient detail was included in the assessments so that informed decisions regarding the suitability of placements could be made. Information gathered from assessments was reflected in individual support plans. In the AQAA, the manager stated that the assessment process had been improved as a result of one deputy being given responsibility to coordinate referrals. This meant that there was one point of call for people making enquiries. In their questionnaires, people confirmed that they had been given written information about the home before moving in. One person said that staff Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 11 visited them in their home, and they visited Lister Avenue on several occasions for meals and overnight stays before moving in. Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person had a support plan, to ensure his or her opinions had been sought and needs assessed. People were supported to make decisions and take risks to ensure they had some control of their life. EVIDENCE: Three support plans were examined. These were well set out and easy to read. Where they had chosen to do so, people had signed the plans to evidence that they had been involved in its drawing up. Plans contained a statement confirming that individuals had access to their plan as they wished. The plans contained a comprehensive range of information covering all aspects of personal, health and social care. The plans identified the staff action required to ensure identified needs were met. Risk assessments were in place, to ensure that all identified risks were well managed whilst providing some independence to people. The plans had been reviewed to make sure they were kept up to date. Whilst the care plans contained sufficient detail, the daily Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 13 records did not fully reflect the day’s events, work undertaken or persons well being. It is recommended that further details be recorded in daily notes so that full information is available to staff, and to match the high standard of recording in care plans. People were able to make decisions about their lives. Individuals were observed making choices about where and how to spend their time, and staff respected these decisions. People said they liked living at the home; the staff were ‘caring’. People spoken with confirmed that they could make decisions, and the routines at the home were flexible. The ethos of this project was to support and empower people. This was reflected and echoed in support plans and discussions with all staff. Regular key work meetings and house meetings promoted people’s involvement with decision-making. Records of these showed that people’s opinions were sought and acted upon. Examples of this are provided throughout the report and include people’s involvement in making decisions regarding menus, activities and holidays, and involvement in staff appraisals and recruitment. Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had opportunities to participate in some activities and holidays to enrich their lives. Contact with families and friends were maintained to support people. People’s rights were promoted and responsibilities were identified. A varied diet was provided and preferences respected to maintain health and well-being. EVIDENCE: A range of activities was offered to people, which included trips out of the home to local shops, clubs and pubs. People had been involved in deciding what holidays to plan; a survey had been carried out with each individual to find out their preferences. Holidays had included a ‘pamper week-end’ and beach holiday. Staff continued to motivate service users. A project party with a Western theme had been organised by staff and people living at the home, people said that they had really enjoyed this. Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 15 The care plans and daily notes seen showed that contact with family and friends were maintained. People spoken with said that they regularly had family visit them. One persons partner was visiting during this inspection, they said that they could visit at any time and were always welcomed by staff. People said that they were responsible for some household tasks, such as laundry and tidying rooms, which they had agreed to. A ‘Know your Rights’ questionnaire was carried out with people so that they were aware of their rights and these were maintained. A central kitchen provided the main meals to people in their houses. Breakfast and snacks were available within each house. The record of food provided was varied and appeared healthy. Alternatives to the menu were always available. People were involved in menu planning, food shopping and meal preparation, to develop and support their independence. A satisfaction survey had been carried out and a ‘service user involvement folder’ had been introduced specifically regarding menus and food so that people s views about the food provided could be taken into account. People said that they enjoyed the food, but preferred the menu when it had been decided at weekly house meetings. A full menu review was planned to take place in September 2008. People were observed helping themselves to snacks and hot drinks, as they needed. There were plentiful stocks of food seen in the main kitchen and in each house. The cook was well organised and carried out all of the required health and safety procedures to minimise risk. Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Despite inadequacies in medication systems evidence shows that people who use the service experience good quality outcomes overall. This judgement is based on the evidence that the service has far more strengths than areas for improvement. We have made this judgement using a range of evidence, including a visit to this service. People received personal support in the way they required. Physical and emotional health needs were identified and met. Some medication procedures had not been routinely adhered to, which placed people at risk. EVIDENCE: Support plans contained information on peoples personal care needs in detail. The plans set out the staff action required to ensure all identified needs were carried out. The support plan recordings were specific and comprehensive. Staff had a clear understanding of people’s individual needs, and the knowledge to ensure personal care needs were met respectfully. People were able to independently meet their personal care needs, plans contained information on encouragement and advice. In their questionnaire, one health professional said Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 17 “One of my clients had poor hygiene/health for years but this is improving with one to one support” Support plans contained information on all aspects of health care. Appointments and treatments with health care professionals were recorded to ensure these were monitored and health was maintained. The plans evidenced that people’s emotional health was monitored and any concerns identified were referred to relevant specialists. Access to health care professionals was available. Staff responded to any health concerns promptly. Written policies and procedures were in place regarding medication systems. Contact with the pharmacist was maintained, and the pharmacist undertook medication audits, in line with written procedures. Medication was stored securely. Support plans included assessments to self-administer, and consent to medication to evidence that safe and informed practices were carried out. The medication administration records examined were accurate, fully recorded and up to date. All staff had undertaken training in safe medication administration. However, the CSCI had been notified of an incident regarding medication that evidenced some staff had not adhered to written procedures, which could have placed people at risk. The management had responded to the medication error promptly and had taken immediate steps to make sure people were safe and procedures followed. Appropriate action had been taken to investigate and respond to staffing issues relating to the error. Further systems to audit medication had been introduced in response to the incident to prevent any reoccurrence. It is important that all staff follow medication procedures and are provided with re training to ensure they are fully aware of these. A system to ensure refresher training is provided in line with written policy must be in place to minimise any future potential for errors. Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s views were listened to and taken seriously. People were protected from harm. EVIDENCE: A written complaints procedure was in place and people had been provided with a leaflet informing them how to complain, should they wish. Neither contained contact details of the local office of the CSCI so that people had this information should they need it. All of the people spoken with said that they would tell their key worker, or other staff, if they had any concerns. People felt listened to and said that staff always helped them if they were worried. No complaints had been received by the home. There was an Adult Protection policy in place, which included the Department of Health guidance `No Secrets’ to ensure staff had access to all of the information needed to promote peoples safety and well being. The organisation had a procedure to provide staff training in adult protection on an annual basis to equip them with the skills and knowledge needed to ensure people were safe, and to respond to any allegations appropriately. Lister Project DS0000002981.V371268.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. We have made this judgement using a range of evidence, including a visit to this service. The home was clean and, in the main, well maintained. Homely touches had been provided to create a comfortable environment. EVIDENCE: Requirements relating to the environment made at the last inspection had all been actioned. Areas of the home had been redecorated. Further crockery and cutlery had been provided and damaged kitchen work surfaces had been replaced. A programme of refurbishment and redecoration was in place; this identified the priority of work that needed doing. All bathrooms were due to be redecorated. People had been involved updating the garden and had chosen seating and ornaments to enhance outside areas. Due to the complex needs of some service users, damage to the environment constantly took place. Some carpets and sofas were marked and dirty. Several people were heavy smokers. In an effort to reduce risk, all of the five Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 20 houses had smoking rooms identified and fitted with extractor fans; other communal rooms had been identified as non-smoking. This created a safer space for non-smokers to benefit from. All of the designated smoking rooms had been provided with a television and sofa for people to enjoy. During the mid day meal it was noted that the hot food trolley used to transport meals to the houses was very unsteady from badly worn wheels. . This must be replaced to minimise the risk of accidents. Lister Project DS0000002981.V371268.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, 35 and 36 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefited from appropriately recruited, trained and supervised staff. EVIDENCE: The staff spoken with had a positive attitude to their jobs and displayed high level of commitment to people living at the home. Friendly and supportive relationships were observed. The homes rota indicated that agreed levels of support staff were being maintained. The rota had been reviewed so that more staff were on duty at core times to carry out activities, and to reduce the need for agency staff. All of the staff reported a good team spirit at the home. Some staff reported that current domestic and cook vacancies meant they had to cover these. This reduced the amount of one to one time available to people. Whilst it is acknowledged that attempts have been made to recruit to these vacancies, these must continue so that support staff are available to concentrate on their duties. Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 22 Three staff recruitment files were checked. They contained all of the information required. Criminal Records Bureau (CRB) checks had been undertaken on all staff so that people were protected. The AQAA stated that people living at the home were actively involved in staff recruitment so that they were part of decision making. Staff undertook periodic training relevant to their job. Since the last inspection all support staff had been provided with specialist training related to aspects of mental health. Dealing with challenging behaviour training had been provided to equip staff with essential skills. In their questionnaire, one staff said “I feel that the training plan we undertake is relevant. We have had excellent additional training, including a five week course on Mental Health Awareness, and ongoing Mental Capacity Act training” The Psychologist that provided the Mental Capacity Act training had also spent time at the home discussing individual work and suggesting new methods of working. A training plan and individual training records were maintained to ensure effective monitoring took place. Of the 19 permanent support staff, 18 staff had achieved NVQ level 2 or 3 in care. This is commended. All staff reported that they had regular supervision, to ensure they received sufficient support and guidance. Records inspected evidenced that staff supervision took place at the required frequency. To promote involvement, people living at the home were involved in staff appraisals. Their opinions were sought as part of this process. Lister Project DS0000002981.V371268.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. We have made this judgement using a range of evidence, including a visit to this service. People benefited from a well run home. EVIDENCE: An acting manager was in post covering the registered managers vacancy, who had been promoted within the organisation. Recruitment to the permanent managers post was taking place and interviews had been planned. People said that the acting manager was approachable and supportive. In their questionnaire, one health professional said of the acting manager “I feel this service has greatly improved and has a brilliant manager” Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 24 A quality assurance system was in operation, to monitor the service and obtain the views of people and their representatives. A quality assurance survey had been carried out since the last inspection so that the views of people living at the home could be acted upon. The results of surveys were published so that they were available to any interested parties. Health and safety systems were checked and serviced. Mandatory training had taken place and systems were in operation to ensure staff were provided with refresher training when needed. As people living at the home had always been independently mobile, and had never needed any assistance, moving and handling training was not included in the mandatory training plan. In acknowledgement that some people living at the home were ageing, it is recommended that this training become part of the mandatory training programme so that staff are equipped to meet moving and handing needs should they ever be required. Fire training was provided to staff over and above the required frequency, in recognition of the fact that the majority of service users smoked, and some discarded their cigarettes in a way that was potentially unsafe. Records showed that fire drills took place regularly. However, there was no system in place to make sure that all staff participated in turn and kept their skills up to date. Since the last inspection the fire system had been updated to indicate the specific location of a fire. Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 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 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 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 3 X X 3 X Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 Requirement Written procedures regarding safe medication administration must be adhered to at all times. Timescale for action 30/11/08 2 YA22 22 3 YA24 23 Staff must be provided with refresher training in medication administration so that they are fully aware of these procedures. The written complaints 31/12/08 procedure must include the full contact details of the CSCI so that people have full information. Marked carpets and sofas must 31/12/08 be cleaned or replaced. The hot food trolley must be replaced to prevent the risk of accidents. Cook and domestic vacancies must be recruited to so that support staff are fully available to people living at the home. 30/11/08 30/11/08 4 5 YA24 YA33 13 18 Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 27 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 3 Refer to Standard YA6 YA17 YA20 Good Practice Recommendations Daily records should include more detail to fully reflect the days events and persons well being so that staff are kept fully informed. People should be further consulted about menus so that their views can be taken into account. A system to make sure staff are provided with refresher training in medication at appropriate intervals should be developed, in line with company procedures, so that skills are maintained and people are kept safe. A system to monitor staff fire drill training should be implemented to make sure all staff participate in training at regular intervals. Moving and handling training should be included in the mandatory training programme so that changing needs can be met when needed. 4 5 YA42 YA42 Lister Project DS0000002981.V371268.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Lister Project DS0000002981.V371268.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. 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