Inspection on 02/05/08 for Cavendish House

This is the latest available inspection report for this service, carried out on 2nd May 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cavendish House 24/06/05

Cavendish House 01/11/04

Cavendish House 17/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Cavendish House Cavendish House 4 Saxbys Lane Lingfield Surrey RH7 6DN Lead Inspector Debbie Sullivan Unannounced Inspection 2nd May 2008 09:15 Cavendish House DS0000013585.V363118.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 Cavendish House DS0000013585.V363118.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. Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cavendish House Address Cavendish House 4 Saxbys Lane Lingfield Surrey RH7 6DN 01342 833297 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) d.elcock@btinternet.com Monica Cantwell Trust Mr Gerald Michael Loney Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18-65 YEARS 8th May 2007 Date of last inspection Brief Description of the Service: Cavendish House is a large terraced house situated in the village of Lingfield approximately eight miles from Horley in Surrey. It provides care for up to five younger adults who have a learning disability. All the bedrooms are single and most are located on the first floor that is accessed by a flight of stairs. One bedroom is located on the ground floor. The home provides communal areas with two lounges, a dining room and a family style kitchen. There is a good size well kept garden to the rear of the property that is enclosed and secluded. There is on-road parking available in front of the house or on the road nearby. Service users have opportunities to take part in a wide range of educational, recreational and social activities. The fees currently range from £3,805 to £2,868 per month. Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over six and quarter hours. During the visit time was spent with the registered manager, service users, a member of the care staff and relatives who were present for a short while. A tour of the property took place and a range of records and documentation including care plans, staff records and medication records were inspected. The homes’ Annual Quality Assurance Assessment document (AQAA) completed by the registered manager provided information to assist the inspection and comments about the service were gained from survey forms sent in by all the service users, some staff and a care manager. The manager, carer and service users present were helpful in providing information for the inspection and are to be thanked for their assistance and hospitality. The quality rating for this service is two star. This means that people who use this service experience good quality outcomes. What the service does well: Cavendish house provides a homely and comfortable environment that encourages independence and offers a range of experiences to help service users to gain new skills and improve existing ones. The home promotes community presence and there is a wide range of educational, social and educational activities on offer. Service users are supported to practise their faith. The staff group is well established and staff know service users well. Effective links are maintained with relatives and the home communicates well with them. Staff like working at the home and contributed positive comments in person or on survey forms. The home is well maintained and service users contribute to decisions about its running via weekly residents’ meetings. Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The statement of purpose needs to be updated. Care plans need further work so that the information in them is easily accessible for staff and service users and is not kept in several different folders. Risk assessments must all be signed and dated and reviewed regularly. The staff training programme needs to be improved so that all staff receive POVA training and regular updates, and the home must continue to actively work towards increasing the number of staff who have an NVQ in care. Supervision must be documented. If the home does not extend there must be further refurbishment of the communal areas as they are looking a little shabby. The hot water temperature throughout the home must always be kept safe for service users. Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 7 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. Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 4. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users have access to information about the home and are welcome to visit before they make a decision about moving in. Needs are assessed prior to admission and service users only move in if they can be fully met. EVIDENCE: Information about the home is available to prospective service users, their families and other representatives. The statement of purpose needs to be amended to give the correct address for the Commission, and the sentence stating that service users have keys to their rooms must be updated, as this is not currently the case. There had been no admissions to the home for several years and the current service user group is well established. Prospective service users are welcome to visit the home before a decision is made about moving in and the manager said that compatibility is viewed as very important. One service user stated on their survey form that “I visited the care home with my parents before I became a resident” and a relative present Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 10 during the visit said that they had visited other possible homes but liked Cavendish House straight away as their first impression was that it was a “home from home”, they felt it had lived up to expectations. Service users are assessed by their local authorities prior to admission and the manager visits them, it was recommended at the last key inspection that the home complete its own recorded pre admission assessment as well. This can be fully assessed when there has been a new admission. The needs of current service users have been reassessed and reviews are held involving the sponsoring authorities. Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users and staff would benefit from further improvement being made to care plans to make them clearer, more accessible and completed in more detail. Improvement is needed to risk assessment documentation. Service users have opportunities to take part in the daily running of the home and are consulted. EVIDENCE: Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 12 The care plans of three service users were read in detail, the information on care plans had improved since the last inspection and there was more information about needs, goals and assessed risks, although risk assessments had not all been signed or dated. Some information was not easy to access as information on each person is contained in several different folders. Reviews undertaken with the day centre, college and with care managers were included as were regular keyworker meetings. The Annual Quality Assessment document says that individual care plans and targets for service users had been reviewed, it was clear that work on this had taken place although further review needs to take place to make sure that information is clearer, accessible for service users, all entries are signed and dated and there is more in depth information on risks and choices. Service users are well supported to make choices about their daily lives and some of these are recorded in residents’ meeting minutes and keyworker meeting recording. For example service users are consulted about activities, meals and social events. A recommendation from the last inspection had been that service users needed to be consulted about holding keys to their rooms, the manager provided evidence that staff had addressed this and said that service users were consulted. Service users had access to keys for their rooms and any associated risks had been considered whilst risks still needed to be fully recorded on individual care plans. Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 People who use this service experience excellent quality outcomes in this area This judgement has been made using available evidence including a visit to this service. Service users are offered a wide range of activities that encourage personal development, community integration and independence. The individual interests of service users are respected and built upon. Service users are supported to keep in contact with relatives and friends. Meals are healthy and varied and service users follow a healthy lifestyle. EVIDENCE: Service users lead very busy and active lifestyles and are supported to pursue individual interests as well as activities with others. Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 14 There is a weekly planner on display and each service user has their own weekly schedule of activities. One service user said that their week included college, where they were working on independence skills such as cooking, helping with meals on wheels, visiting elderly people at home and in residential care, swimming, a prayer meeting, attending a local day centre and a drama group. Another service user enjoys gardening and gardens in the community and another does a part time paper round for which they receive payment. One day a week is a “home” day when the residents’ meeting takes place and housework is done, each service user has designated tasks, all were doing some housework during the visit. Service users are supported to follow their faith and are active in local churches. The home is to be commended on its work in the community; it’s integration, and the extent to which each service user is able to pursue their own interests and is supported with new experiences. On the day of the inspection two service users had already left to visit relatives for the bank holiday weekend and the others were all going to their relatives that day. One service user was going abroad for the first time the next day. The service user was flying for the first time and in preparation the manager had taken him to Gatwick Airport for a familiarisation visit that was a success. Another parent collected a service user later in the day and said that they were very satisfied with the lifestyle offered at the home, the service user was more active had lost weight and was fitter, was more helpful and aware of others needs and they “could now treat (service user) as an adult.” A letter received from a family shortly after the inspection echoed positive views and stated “We are pleased that (service user) has been able to continue to practise his faith in an active way, which is a very important part of his life”. A survey form from a care manager stated that their service user was “supported to follow a healthy diet and maintain an active lifestyle and was fully integrated into the community locally and a valued part of various projects in the local community”. Service users are supported to take annual holidays. Relatives spoken with and who wrote to the Commission said that the home maintains good relationships with them and communication is good. Relatives were clearly very at ease and welcomed when they arrived to collect the service users. Service users were joined at the breakfast and lunch table, the meals were relaxed with lots of pleasant chatting between the manager, carer and service users. The food was healthy and nicely presented with choice available. One service user said, “The meals are fantastic”. Another said that they had been Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 15 supported to lose weight and at first was not keen on some healthy foods but had grown to appreciate them more and knew the weight loss was beneficial. During the visit service users were accessing the home freely and could choose to spend time alone or with others. Cavendish House DS0000013585.V363118.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. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service users are well met and service users are encouraged to be independent with their personal hygiene. EVIDENCE: As the staff group is very stable and all the service users have lived at the home for at least three years staff are very aware of their individual needs. Each service user has a key worker, service users spoken with knew who their keyworkers were. Some health information is held in the care plans, the manager has stated in the Annual Quality Assurance document that Health Action plans are to be developed. Most service users are mainly self-caring; two need support and prompting with personal care. Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 17 Service users are supported to attend routine medical appointments and if necessary specialists such as epilepsy consultants. The manager said that the service users kept very healthy, their active lifestyle and good nutrition play help with this. One service user has a history of self-harming, incidents have decreased and staff know how to support the person and manage the behaviour. A relative wrote in their letter that “His ability to care for himself in regard to his clothes and hygiene is not good, but the encouragement and understanding from the very dedicated staff has helped him to improve”. The routines of the home are flexible depending upon the day’s activities and during the visit service users got washed and dressed, ate breakfast and cleaned their rooms in their own time. Medication procedures had improved since the last inspection as now handwritten entries on MAR sheets are signed by staff and the MAR sheet folder has a list of staff qualified to administer medication. One service user manages their own medication; there is now a risk assessment for this. Medication is stored securely. Cavendish House DS0000013585.V363118.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 this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and the views of service users and others are taken seriously and acted upon. The home has measures in place to protect service users; these can be improved with the provision of adult protection training for all staff. EVIDENCE: There is a complaints procedure, no complaints had been recorded since the last inspection and there have been no safeguarding vulnerable adults alerts. Service users who sent in survey forms and who were present during the inspection said that they knew who to approach if they had concerns, and a member of staff said that service users are reminded of the procedure at residents’ meetings. Staff survey forms showed that staff are aware of the procedure, one comment was that “I feel confident that I would know what to do if someone had concerns about the home”. Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 19 Relatives spoken with during the visit also felt confident in raising any issues, they had had no concerns and said the manager and staff were approachable. The majority of staff have now undertaken POVA training and the manager said that training was to be provided for the two remaining. A member of staff spoken with confirmed they had had training and understood what constituted abuse. The home has a safeguarding policy and has a copy of the local authority multi agency safeguarding procedure. Recruitment procedures are good and all staff are CRB checked. Cavendish House DS0000013585.V363118.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): 24,25,26,27,28 and 30 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, clean and well-maintained environment. Bedrooms are suited to individual needs and are personalised. Some refurbishment is needed to communal areas. EVIDENCE: The home is in a quiet street near to the centre of Lingfield, this is an advantage as service users are very active in the community. A care manager stated on a survey form that there was a “homely feel and generally appears a pleasant environment”. Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 21 The home is well decorated, clean and well maintained; there are areas that need some refurbishment such as the lounge and dining area. If the home is not to be extended as has been planned for some time the refurbishment should not be delayed, it is on hold whilst plans are decided upon. Service users’ bedrooms are suited to their needs and personalised with photos, pictures and items that reflect their interests. One bedroom had recently been fitted with new large wardrobe sized cupboards; the service user was pleased with them. Service users said they liked their rooms; all were dusting them during the visit as it was the “at home” day. Bedrooms all have wash hand basins. There is a toilet and bathroom downstairs and bath/shower room upstairs, the water in the upstairs bathroom was very hot; the manager undertook to look into this. The kitchen leads off the dining room and was clean and tidy, an environmental health visit in August 2007 had identified a problem with the fridge so a new one had been purchased. There is a large lounge leading off the dining area and a smaller lounge near the staff office where private visits and meeting can take place. The garden is attractive, enclosed and well maintained, mostly by a service user who likes gardening. Cavendish House DS0000013585.V363118.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): 31,32,33,34,36 and 36 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. An established staff group that is competent and able to meet their needs supports service users. Staff are well supported and recruitment procedures are thorough. Some areas of training need improvement. EVIDENCE: The manager and care staff provide support to the service users, the manager is supported by a part time personal assistant on a voluntary basis with some of the administration. The manager and one carer were on duty during the inspection, it was a slightly unusual day as all the service users had either gone away or were Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 23 going away for the weekend, the manager was later driving one to family in another county. The staff team has remained stable for some time so staff are very familiar with needs, no agency staff are ever used. Training has improved since the last inspection as the majority of the staff have now received POVA training, the manager said that he intended to improve external training overall. Staff files showed that up dated training had also now taken place on core topics such as infection control and food hygiene. Staff have opportunities to go on specialist training including epilepsy, Downs Syndrome and dementia and equality and diversity training had been provided. The home has not yet reached the target of having at least 50 of staff who hold an NVQ in care although, three have the qualification and three more are working towards it. Six staff members returned survey forms to the Commission, staff felt they were well supported, kept aware of any changes in the lives of service users and that training was good, comments included “All training given has been of a high standard” and “information is shared effectively”. Staff files read during the visit included the required recruitment documentation, CRB numbers are retained. CRB’s are renewed three yearly. Staff receive regular supervision although it was not being fully documented. During the visit service users and staff had a good rapport with each other, a relative commented that staff provided a “good balance of discipline and information”. A service user said “Staff are perfect”. A member of staff said they enjoyed working at the home, had a high regard for the service users and that staff supported each other well. Cavendish House DS0000013585.V363118.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): 37,38,39,42 and 43 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of service users and staff and there is an open and inclusive atmosphere. The views of service users about the home are sought and taken seriously. EVIDENCE: The registered manager is well qualified for the role and has long experience of working at the home. Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 25 The atmosphere is that of a family environment and it is open and welcoming, the views of service users, staff and relatives echo this. Service users are consulted about the running of the home at the weekly residents’ meetings, in person and at keyworker sessions. Quality assurance surveys have now been introduced. The trustees undertake Regulation 26 visits to the home; the record of visits was not available on the day of the inspection as it was being updated, the manager said that the visits take place regularly. The outcomes for service users living at Cavendish House are good and the home is well managed. The service needs to make sure that evidence of the trustees visits are kept in the home, and can be read at future inspections to evidence that any shortfalls or need for improvement noted by the trustees are recorded and acted upon. Records are kept safely and securely and a business plan for 2008 has been drawn up for the service. Valid insurance is in place and fire equipment is serviced as required. Quarterly fire evacuation practices are recorded that involve service users; good responses have been recorded. A risk assessment of unguarded radiators has taken place, staff have had some updated training on safe working practices and the water has now been tested for Legionnaires’ disease as was required at the last inspection. The temperature of the water in the upstairs shower room must be monitored and be at a safe level. Cavendish House DS0000013585.V363118.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 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 X LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 2 X X 2 3 Cavendish House DS0000013585.V363118.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 YA36 Regulation 18(2) Requirement Staff supervision meetings must be recorded and available for inspection. Timescale for action 01/06/08 2. YA42 134(a)(b)(c) Water in all areas accessible to service users must be kept at a safe temperature. Risk assessments on the supply and appropriate temperature of hot water must be in place and have been formulated after immediate consultation with the EHO/HSE to ensure the Health and Welfare of service users. 30/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 28 No. 1. 2. Refer to Standard YA1 YA6 Good Practice Recommendations It is strongly recommended that the sentence referring to keyholding in the statement of purpose be updated. It is strongly recommended that care plans be streamlined and the main care plan information be kept in one folder for ease of access. All risk assessments must be signed and dated with the date of completion and review. It is recommended that refurbishment of communal areas take place if the home is not to extend within the next year. It is recommended the full names of staff be included on the rota. It is strongly recommended that records of Regulation 26 visits be available for inspection in the home at all times. 3. 4. YA9 YA24 5. 6. YA33 YA39 Cavendish House DS0000013585.V363118.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Cavendish House DS0000013585.V363118.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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