Care Home: North House

What the care home does well North House provides a good standard of care based on normal living principles and community integration for people who have mental health problems. They prioritise residents` needs ensuring that their wishes and feelings are respected. They provide individualised care and demonstrate a commitment to enabling residents to have control over their lives, and where possible assist them to returned to independent living. The home is comfortable and homely. Bedrooms are decorated and furnished to reflect residents` need, interests and personalities. There is a range of social and informative activities available to residents. There is a stable, core staff team who provide a homely and caring environment for the residents. The cook provides home cooked meals, including homemade cakes, to a good standard, and residents praised the quality of meals provided. What has improved since the last inspection? The home continues to provide a good standard of care. Since the last inspection in June 2006 the home has made a number of improvement some of which were: A new suite in the lounge A new suite in the conservatory New curtains in the lounge New office furniture New washing machine and tumble drier They had also discussed with the residents a `no smoking` ban in the home. Although voted for by the all of the residents at the time it has not been popular with everyone and may be revisited. CARE HOME ADULTS 18-65 North House 126 - 128 Northampton Road Market Harborough Leicestershire LE16 9LR Lead Inspector Mrs Carole Burgess Unannounced Inspection 23rd July 2008 09:45 North House DS0000001719.V368800.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 North House DS0000001719.V368800.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. North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service North House Address 126 - 128 Northampton Road Market Harborough Leicestershire LE16 9LR 01858 432751 01858 466916 willaminavert@aol.co.uk 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) Mrs Willamina Vert Vacant Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration. Date of last inspection 6th September 2006 Brief Description of the Service: North House is a 12-bedded residential home for people with mental health needs. The home has been open for about 20 years and is situated within ten minutes walking distance of the centre of Market Harborough. There are ten single bedrooms and one double room. One of the single bedrooms on the ground floor has en suite facilities. There are sufficient toilet and shower facilities for other residents to use. There are two lounges, two dining rooms, two kitchens, and laundry room. At the rear of the home is a conservatory, which looks out over the homes attractive small garden, with a patio and seating area. All meals are freshly prepared on site by the home’s cook. The Statement of Purpose, Service Users’ Guide & Inspection Report are available on request (these provide information on how the home is organised and what services they provide). At the time of the site visit the Manager stated that weekly fees were: £350 £813.56. North House DS0000001719.V368800.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 stars. This means the people who use this service experience good quality outcomes. ‘We’ as it appears throughout the Inspection Report refers to ‘The Commission for Social Care Inspection.’ The focus of the inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who use the service and their views of the service provided. Planning for the inspection and report included reviewing the Annual Quality Assurance Assessment (AQAA), which is a self assessment tool completed by a representative of the service, reviewing the previous inspection report, assessing notifications of significant events, any complaints about the service and reviewing the home’s service history to date. The site visit was unannounced and took place over six hours. We selected two residents and tracked the care they received through a review of their records, discussion with them (where possible), other people who use the service, the care staff, and observation of care practices. We spoke with staff members regarding training and support. We sent out pre-inspection surveys to people who use or are involved with the service. We received seven replies from staff and four replies from residents. The surveys indicated that this is a good service and that residents are well cared for by caring staff. Residents said, ‘I am quite happy here and want to stay in this happy place’, ‘the home is kept spotless’, ‘I feel staff are more like friends’. ‘I don’t really differentiate between staff and residents’, and one person said ‘I would just like to say this place has literally saved my life and that is no exaggeration’. A member of staff said, ‘The service take great care to make sure every resident has the support they need to make their stay at North House a happy one, and also a beneficial one’. A number of residents who had lived in the home for many years said that it was comfortable and clean and that they were very well cared for. They said that they lived the life they chose with the support of caring staff. They also said that the food was very good and that there was always a choice and that they could have drinks and snacks at any time. The Registered Provider, Manager and other staff and residents spoken with were positive and helpful during the inspection. North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 7 The home continues to provide a good standard of care. Since the last inspection in June 2006 the home has made a number of improvement some of which were: A new suite in the lounge A new suite in the conservatory New curtains in the lounge New office furniture New washing machine and tumble drier They had also discussed with the residents a ‘no smoking’ ban in the home. Although voted for by the all of the residents at the time it has not been popular with everyone and may be revisited. What they could do better: Requirements: This is what the home must do to improve the service: The Registered Provider (owner) must ensure that all staff files contain all of the required necessary information, including references, which must be available in the home for inspection. Recommendations: This is what the home could do to improve the service: The Statement of Purpose and Service Users Guide, which also includes the complaints procedure, requires updating and the contact details for local Social Services and CSCI should be included so that people have accurate and current information when making a decision if the home is the right one for them. The home’s risk management strategies and risk assessment should identify responsible (allowable) risk taking for individual residents, such as going out unaccompanied where this may, in some circumstances, pose a risk to the resident’s safety, and identify action to be taken to minimise risks without limiting the resident’s choices, independence and personal development. North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 8 Controlled Drugs (CD) (including Temazepam) should be stored in a metal cupboard that complies with current regulation and guidance issued by the Royal Pharmaceutical Society of Great Britain and recorded in a bound a numbered book, checked and signed by two members of staff, to ensure that CD’s are managed safely. Staff who administer residents’ medication should receive annual, updated training to ensure that they have current knowledge to manage medicines safely. Information about advocacy services should be provided so that residents can access independent advice if they need to. The home’s safeguarding policy and procedure requires updating to include and reflect current local guidance. All staff (including ancillary staff) should have Safeguarding Vulnerable Adults training so that they have current information regarding local safeguarding policies and procedures. . 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. North House DS0000001719.V368800.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 North House DS0000001719.V368800.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): 1, 2 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with information about the home, and have their health, welfare and social care needs assessed, so that they can be met once they move into the home. EVIDENCE: The home provides prospective residents and their relatives with a Statement of Purpose and Service Users Guide (both give information about the home) to help them decide if the home is the right one for them. Signed copies of residents’ Terms and Conditions (contracts) were kept in residents’ files. However, the information provided in the Statement of Purpose and Service Users Guide required updating and should include contact details for Social Services and the CSCI so that residents and their relatives or representatives have correct and current information. (This should also be updated in the complaints policy and procedure that should be included with the Service Users Guide). North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 11 Both resident’s files contained a pre admission assessment and the supporting local authority’s ‘Comprehensive Assessment and Outline Care Plan’. The assessment included personal details, relative and GP contact numbers, past and present medical history, current health care requirements, medications and a social history. The pre-assessment process and documentation were satisfactory ensuring that residents’ health, welfare and social needs could be met. One resident wrote on the pre-inspection survey form that, ‘when the opportunity arose (to live at North House) I jumped at it. I knew it was what I needed and wanted’ & ‘I asked questions over and above the required information ….any fears I may have had were allayed’. North House DS0000001719.V368800.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 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are looked after in respect of their personal and social requirements, and are enabled to make choices, take acceptable risks, and to have their needs met within their capacity to do so. EVIDENCE: Residents are very much involved in the care planning process. Residents are able to make decisions regarding their lifestyle and are enabled to take reasonable risks. North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 13 Care plans and daily records contained information about the support residents required in their daily lives. Many of the residents who live at North House have some degree of short-term memory loss. Risk assessments had been completed in the residents’ care plans in relation to specific, individual activities, such as smoking but it had been noted by the local authority that a specific resident may have some difficulties when going out alone. There was no risk assessment showing ‘allowable risks’ associated with this activity. The resident was now able to safely go out alone to specific places and had made progress whilst living at North House. This was not obvious when reading the care plan and therefore did not demonstrate the improvement in the resident daily life or the good work done by the home. Care plans could have been more organised to enable easier access to information. The Manager said that she recognised that this was something which she needed to address and would be doing so in due course. Residents who were spoken with said that they could choose how to spend their day. A resident said that s/he had certain interests and made use of the library, museum etc and local walks and said ‘This is exactly the way I like it’. Residents said that they had been involved in the home’s recruitment process and were part of the interview panel for new staff. They were very clear that it was their home. One resident said it was very important that staff ‘fitted in’ and ‘got to know the residents well as the home was like one big family’. North House DS0000001719.V368800.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 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff ensure that residents experience a safe and homely life style which is appropriate to their age and expectations. EVIDENCE: Residents’ files contained details about their activities and interests. The Manager has stated a daily activities log, which provided an insight into the daily activities of the home and residents. North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 15 Residents are well supported by the staff and the Provider (owner) who takes an active roll in the home. Family and friends are encouraged to maintain contact. Residents go out and about either alone or with the support of staff if necessary. They walk to the local town, use the local leisure centre, go swimming, or use the gym, go shopping, visiting the bank or go to the park. The Provider had recently walked into town with a resident and she had taken her for tea and a cream cake, which the resident said was ‘lovely’. Another resident said her passion was reading and that she regularly went to the library, taking out eight books at a time, which she always enjoyed reading. There is a company vehicle and residents go out on trips and had recently visited East Carlton Park and West Lodge Farm Park. Residents said that they had been on trips to the coast and to garden centres and that they are able to do the things that they enjoy. These activities ensured that the residents interact well with the local community and have a fulfilling lifestyle. Residents had started having meetings with the Manager and staff. Two residents said that these were well attended and that staff listened to their concerns, took their advice, and made changes where necessary. One resident said that they had asked to have tea at a later time. They were not hungry after a good cooked lunch. The time had been changed form 4pm to the later time of 5pm as requested. Residents’ rooms were highly personalised and indicative of their personal tastes and lifestyles, which were encouraged and supported by staff. Menus provided a healthy variety of food and were very flexible to meet the individual needs and preferences of the residents. No one required a special diet but these could be catered for if required. The cook makes home made cakes daily, which the residents enjoy in the afternoons. One resident said that he could do what he wanted, when he wanted and staff would adapt meal times to suite his needs. North House DS0000001719.V368800.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 & 20. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are well looked after in respect of their health and personal care. EVIDENCE: At the time of inspection all of the residents were independent in respect of personal care, requiring only prompts; that is they did not require physical assistance with washing, dressing or toileting, although this assistance would be given if required. Residents’ care plans contained details about individual healthcare needs and had been reviewed and updated as required. North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 17 Medication policies and procedures were satisfactory and residents received their medication as prescribed. Medication was stored safely in a locked cupboard. However, to fully comply with the requirements of the Misuse of Drugs Act 1971, Misuse of Drugs (Safe Custody) Regulations 1973, Misuse of Drugs Regulations 2001 and Misuse of Drugs and Misuse of Drugs (Safe Custody), it is recommended that the home installs a recognised *metal Controlled Drugs (CD) cupboard, fixed to a wall, and maintains a CD register in a bound and numbered book to ensure that these medicines are kept secure and serve as a constant reminder to care workers that these medicines are potent. Although medicines had been administered correctly it is further recommended that staff should receive annual medication training to ensure that they keep abreast of good practice and continue to administer residents’ medication safely. *Temazepam must be stored in CD cupboard. Records of its use in a CD register are expected as good practice but are not a legal requirement. North House DS0000001719.V368800.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 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for receiving and responding to complaints are satisfactory resulting in protection of residents’ rights. EVIDENCE: The CSCI has not received any complaints regarding the home. The home has not received any complaints from residents or their relatives since the last inspection. The information regarding complaints required updating to include contact details for Social Services and the CSCI. This and information about advocacy services should be made available so that residents and their relatives or representatives have the correct, current information should they need to make a complaint or require independent advice. Staff were not clear about the role of Social Services in Safeguarding Adult procedures and the home’s safeguarding policies and procedures require updating to reflects the current local Multi Agency Policy & Procedure For The Protection of Vulnerable Adults from Abuse, No Secrets’ publication, of which North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 19 the home had a copy, to ensure that staff have current guidance on safeguarding vulnerable adults. It is recommended that all staff receive ‘Safeguarding Vulnerable Adults’ training as soon as possible so that they are fully aware of the correct policies and procedures, and of their roles and responsibilities for safeguarding people in their care. Residents said that they felt very safe living at North House and never had any need to complain. North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 20 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, 27 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comfortable, clean, homely and safe standard of accommodation is provided for the residents. EVIDENCE: The home was safe and well maintained with adaptations to suit residents’ needs. It is decorated and furnished to a good standard that created a comfortable and homely environment, and was fresh and clean on the day of the site visit. There was a main kitchen where the cook prepared the residents’ meals and a smaller kitchen where residents could make drinks and sit and chat. There was also a small laundry room and residents who are able can do their own North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 21 washing if they wished. One resident said she did all of her own hand washing and was doing so at the time of the visit. Individual bedrooms were well decorated and furnished to reflect the personalities of the residents who live there. One room had en suite facilities and there were also two bathrooms with showers and toilets for the other residents to use. North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 22 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, 34 & 35. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff at the home are competent and sufficient in numbers to meet the residents’ needs but staff. EVIDENCE: There were ten residents at the time of the inspection. Staffing levels, at the point of inspection, were in line with those suggested by the Department of Health Residential Forum Guidelines and were sufficient to meet the current residents’ needs. There were two staff on duty during the day (one of which may be the Manager) and a one carer at night. There was a cook during the morning who prepared lunch and a part-time handyman for maintenance work and gardening. North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 23 Residents said that they felt that there were sufficient staff to care for them. They said that there had been some staff changes but the staff who had been there for a long time knew them well. One resident said how important it was to have the same staff so that they felt comfortable with each other. Another residents said that, in the past, residents had been involved with recruiting new staff and this was important to ensure that staff ‘fitted in’ so that they could maintain the ‘family atmosphere’, which they valued. Three staff files were checked during the inspection. Two did not contain the correct reference checks. One had only one reference; the second did not contain any. Both were for bank staff who had worked at the home occasionally and had done so for some years and were employed prior to the new Manager being in post. The Manager agreed that she would not use these staff until the correct references had been obtained, or replaced, as they may have been lost. The most recent staff file, completed by the Manager, showed that there had been a robust recruitment procedure and contained all of the correct checks to ensure the that residents were well protected. The Manager had started a training matrix for all staff, which indicated their training needs. Staff have, in the past, undertaken training in food hygiene, first aid, medication, health & safety and moving and handling. On the day of the site visit staff were having training about sensory impairment. An application has been made to Skills For Care to address any training deficits. The Manager had also introduced a new induction workbook for new staff – ‘First Steps, Leicestershire Social Care Development Group’. The Manager also said that five of the care staff had National Vocational Qualifications (NVQ’s) in Care and another three people were doing NVQ’s. This and a planned programme of annual, mandatory training would ensure that staff continue to have the necessary skills to give safe care to the residents. The Manager had undertaken a course in May last year about staff supervision (a regular review of staff’s personal and training needs in relation to their work) and will ensure that all staff receive annual appraisals and supervision. The implementation of the training matrix, and regular, recorded supervision, should ensure that staff have their training needs identified and that they have the necessary skills to provide a good service for the residents. All seven care staff who responded to the pre-inspection surveys said that they felt that they had been given the induction, support and training they needed to care for the residents. One staff member said that staff had ‘good experience and training to work as a team’ and ‘support each other and develop as a whole’. North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 24 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 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager provides supportive leadership to staff, ensuring that residents receive a good standard of care. North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 25 EVIDENCE: The new Manager has had some years of experience in care, both as a carer and deputy manager of a care home. She had an NVQ in Care, Level 4 and the Registered Managers Award (RMA) and was in the process of applying for registration with the CSCI, which will further demonstrate that she has the necessary skills and is ‘fit’ to manage a care home. There was an ethos of warmth and openness in the home and staff deliver a good standard of care and were well organised. Health and Safety Policies and Procedures, such as regular recorded fire drills, fire alarm tests and regular equipment maintenance had been completed and showed that the Registered Provider and Manager was mindful of her responsibilities to make sure that residents live in a safe environment. Both residents and staff have had minuted meetings since the new Manager has been in post. Residents said that being part of a small home meant that most issues were sorted out on a daily basis, but things brought up at meetings were addressed, such as happened with changing tea time 4pm to 5pm to suit the residents (see page16). The residents’ personal allowances were checked. Some residents manage their own finances and have their own bank accounts. Others need some support from staff. Personal allowance money kept in separate envelopes for each resident and were locked in a cupboard. Records of transaction were maintained to show the deposits and withdrawals and were signed by staff and the resident to ensure that the balance was correct. North House DS0000001719.V368800.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 2 2 3 3 X 4 X 5 3 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 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 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 3 12 3 13 3 14 4 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 4 3 X X 3 X North House DS0000001719.V368800.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. 1. Standard YA34 Regulation 19 Requirement The Registered Provider (owner) must ensure that all staff files contain all of the necessary information, as described in the Care Homes Regulations 2001, Regulation 19, Schedule 2 & Schedule 4.6, including references which must be available for inspection. Timescale for action 23/08/08 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 YA1 Good Practice Recommendations It is recommended that the Statement of Purpose and Service Users Guide requires updating to include all of the information contained in Care Homes Regulations 2001 4 (1) & Schedule 1 and include contact details for local Social Services and CSCI. It is recommended that the home’s risk management strategies and risk assessment should identify responsible DS0000001719.V368800.R01.S.doc Version 5.2 Page 28 2. YA9 North House 3. YA20 4. 5. 6. 7. 8. YA20 YA22 YA22 YA23 YA23 risk taking for individual residents, such as going out unaccompanied, and identify action to be taken to minimise risks without limiting the residents preferred activity. It is recommended that Controlled Drugs (including Temazepam) is stored in a metal cupboard which complies with current regulation and guidance issued by the Royal Pharmaceutical Society of Great Britain, and are recorded in a bound and numbered book and checked and signed by two members of staff. It is recommended that staff who administer residents’ medication receive annual updated training. It is recommended that the complaints policy be updated to include contact details of local Social services and CSCI. It is recommended that information about advocacy services are provided. It is recommended that the home’s safeguarding policy and procedure requires updating to include current local guidance. It is recommended that all staff (including ancillary staff) should have Safeguarding Vulnerable Adults training. North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 North House DS0000001719.V368800.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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