Inspection on 01/04/08 for Portway (200)

This is the latest available inspection report for this service, carried out on 1st April 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Portway (200) 25/09/06

Portway (200) 11/10/05

Portway (200) 27/07/05

Portway (200) 06/10/04

Portway (200) 14/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Portway (200) 200 Portway Stratford London E15 3QW Lead Inspector Anne Chamberlain Unannounced Inspection 1st April 2008 11:15 Portway (200) DS0000022846.V361673.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 Portway (200) DS0000022846.V361673.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. Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Portway (200) Address 200 Portway Stratford London E15 3QW 020 8552 9164 NO FAX gary.reeman@east-living.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) East Living Limited vacant post Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th December 2007 Brief Description of the Service: Portway is a care home for up to six people with learning disabilities and challenging behaviour. The residents have been living together for over 10 years. The building is a large house situated opposite West Ham Park, close to local amenities and Stratford shopping centre. There is a rear garden with a summer house, shed and greenhouse. The Registered provider of the service is East Living, part of the East Thames group. Fees paid at the home are around £1,658.00 per week. Portway (200) DS0000022846.V361673.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 that people who use the service experience good quality outcomes. The last inspection of this home was a random inspection which took place on 10th December 2007. Five requirements were made at that inspection and they were tested at this inspection. This is the fifth time I have inspected this home and it was an unannounced key inspection. It lasted for nearly 7 hours and I was assisted by the deputy manager in the morning and the manager in the afternoon. I had an opportunity to exchange greetings with all the residents at the home during the course of the day, and several staff members, some of whom I know from previous inspections at the home. During the course of the inspection I looked at policies, procedures and records, the personal files of two service users and three members of staff. I also viewed the arrangements for the administration of medication. I toured the premises including some bedrooms, and the garden and summerhouse. I would like to take this opportunity to thank the service users, staff and managers at the home, for their co-operation and assistance with the inspection. What the service does well: The service provides a very comfortable home for the service users. It supports them to live together amicably. Staff understand the complex needs and behaviours of the service users and plan carefully to meet them, working in a consistent way. Service users are supported to undertake a range of activities outside of the home, as well as making short local trips with staff. The manager of the home is open to developing and improving the service and has demonstrated an ability to do this. Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The inspection has resulted in six legal requirements and two good practice recommendations. None of the requirements are restated. The electricity supply in the home is subject to constant interruption. The fixing of this is a high priority to be addressed urgently. There is scope for more activities to be planned and arranged with and for service users, including holidays. There is scope to encourage and develop more choice of food and meals among service users. Quality assurance can be developed further with more meaningful tenants meetings and discussions with service users; Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 7 There is a proposed move for one service user and the home will be managing and supporting this. The service users will all need support to cope with the change. 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. Portway (200) DS0000022846.V361673.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 Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service has a structure in place to facilitate quality assessment and introduction to the home. EVIDENCE: I viewed the admission policy which has been written by the organisation Outward. The policy demonstrates good practice in assessing and introducing a new service user into the home. Issues of compatibility would be considered. The manager stated that in addition to following the policy they would complete a standard assessment format which is comprehensive and detailed. No new person has been admitted to the home for some time but should this happen I felt that it would be sensitively handled, and service user choice fully considered. Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Service users experience Quality in this outcome area is (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each service user has three files and I inspected the files for two service users, six files altogether. The standard of service user plans was high in both cases. Both service users have complex needs and their verbal communication is unique to them. Their needs were well described and care staff are well supported to communicate and work with them in a consistent way. The plans are complemented by behaviour guidelines and health plans. The information is well organised, detailed and consistent. Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 11 The care plan for one individual had not been signed by her and was not dated. The health plan did not have the action plan completed, and was not signed or dated. The care plan (Person Centred Plan) for the other individual was signed and dated and a second plan (Personal Living Plan) had a good front sheet which explained the service users involvement, and how the document had been compiled. The health plan was not signed or dated (a requirement has been made). There was evidence that care plans are reviewed regularly, generally every six months. I felt that service users are encouraged to take decisions themselves and that being involved in new activities has given them more scope for this. Communication is key to understanding the choices that service users make and I was impressed by how well staff understood the verbal communication of the service users. Some of which is individualised. The service user who uses Makaton now has a keyworker who can sign. The manager and I agreed that more decisions and choices regarding food and meals could be taken by service users and this is dealt with later in the report. There was evidence that service users are supported to take risks as part of their lifestyle. The level and quality of risk assessment was good with a variety of activities being assessed and actions to reduce risks identified. Some risk assessments had been signed by a service user, and some had not. Service users should understand how risks are managed with and for them and it is good practice for them to sign their own assessments where possible. Alternatively as mentioned above a statement can be added to describe the level of service user involvement. (a recommendation has been made). All risk assessments must be dated to facilitate regular review (a requirement has been made). I noticed that at the back of one file some old risk assessments. These duplicated the current ones. If they cannot be archived they should be labelled as old, to eliminate duplication and confusion ( a recommendation has been made). Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Lifestyle options are good and improving for people. Life inside the home is quieter and less stressed generally. EVIDENCE: I noted the laminated weekly programmes pinned up for service users and staff to see. They have some pictures but the manager said more needs to be done to make them really user friendly. Service users are enjoying an increased level of activities outside of the home. They access college, Bow Centre, football, writing therapy, hydrotherapy, healthy living group, regular West End theatre trips, etc. The manager said that he has invited a home entertainment group to come and do a show for the service users. He said that he is aware people could be doing more and that Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 13 the deputy manager is good at identifying and locating suitable activities. He also said that staff have noticed how much service users benefit from getting out and about with quieter, calmer behaviour at home. One service user is a very competent cook and she was helping prepare the dinner on the day of the inspection. Where service users have contact with families this is well supported by the home. Family views are taken into account. Breakfast and lunch are multi choice affairs with the usual appropriate foods on offer. At present residents meet on Sunday evenings and decide what meals should be on the menu for the dinners the following week. They use magazine pictures and pin them on the board. A note is kept of what is eaten and I noticed that every evening all the service users eat the same meal. In my experience it is most unusual for six people to all want to eat the same meal on the same night. The manager agreed that more individual choice could be encouraged and supported. He said that he felt actual photographs of the dishes prepared at the home would be much more realistic than the magazine pictures, and would help people to recognize and choose dishes more easily. Work could be done around dinner time with people to find out if they would like an alternative on that particular evening. The manager has recognized that this is an area for development. I look forward to seeing progress in due course. Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The support offered to individuals is tailored to meet their needs. Their physical and emotional health is monitored and met. Medication practice is sound. EVIDENCE: The health information on file evidenced an individualised approach. Between them the service users see a number of different specialists and all the regular health checks like dentist and optician are undertaken. One service user is diabetic and his blood sugar is monitored at home and by the local clinic. One service user is epileptic and this is very well controlled. I felt that the emotional needs of service users are well monitored. There is a strong link between emotional state and behaviour for most of the service users and I felt that staff were very attuned to this. They co-operated Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 15 together in trying to discover what was bothering one person because they could tell he was unsettled about something. I inspected the arrangements for the administration of medication. The home has a new cabinet which just needs to be put up. It will be larger than the existing one, which is too small. The home records medications coming into the home and returned to the pharmacy. They get the pharmacist to sign for medication returned to him and this was evidenced. The home uses a blister pack system and I examined two Medication Administration Record (MAR) sheets and balanced two medications. Both had the correct amount of medication left. The home keeps a good checking system, a bit like an accounts book, deducting every tablet taken off of a total. This helps them to undertake regular checks and balances and detect any medication error quickly. I was quite satisfied with the arrangements for the administration of medication. They are supervised by the managers at the home and safeguard residents. Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and handled well. There is an open attitude to service users complaining but they need encouragement to do so. EVIDENCE: The home has a complaints book which the inspector viewed. The last complaint was in December of last year. It was appropriately dealt with. The complaints information has a timescale and there is a user friendly version with a simple explanation and pictures. The manager said that service users rarely complain and he would like to find ways to encourage them to be more assertive. We agreed that as things improve generally at the home we would expect service users to become more aware of their own views and able to articulate them. I noted in the complaints book a compliment. A family had said how nice it was for their daughter to come home with flowers for her Mum on Mothers Day. I viewed the arrangements for the handling of service users monies. Staying with the two residents whose files I viewed I checked their cash balances and bank books. Everything appeared to be in order. People seemed to be having Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 17 good access to their own monies to buy everyday treats like magazines and drinks, as well as larger items. Receipts were kept for everything bought. The home has an organisation policy for the safeguarding of adults and now has a copy of the local authority policy which is to be followed in conjunction with their own. Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Service users experience adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable environment for service users. It is clean and homely and the outdoor facilities are particularly nice. However the intermittent loss of electrical power is longstanding and disruptive for service users and staff. EVIDENCE: Before the inspection I had become aware that Portway was experiencing intermittent loss of electrical power. The deputy manager confirmed that this was the case and that the problem has been going on for months. Apparently the fault has been diagnosed, but the home await contractors to fix it. I was told that service users, one in particular, are adversely affected by the uncertain nature of the electrical power. Sometimes it is restored quickly and Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 19 at other times it takes longer. Obviously this is disruptive and frustrating for service users and staff and quite unacceptable in a residential home. Whilst at the home I made a telephone call to a senior manager. I have also made a requirement with a timescale of one month. I inspected the home, including some bedrooms, the summer house and the garden. The home looks very nice from the front with a hanging basket of spring blooms and more plants in a pot on the window ledge. Overall the standard of décor at the home is good. There are a few issues but the manager assures me that these have all been reported and he awaits the maintenance department to come and do the necessary work. The home is going through phase where some service users are regularly breaking toilet seats. Two were broken off at the time of the inspection. The manager is trying to find a type of seat or fixing which will be more resistant to breakage. He will be speaking to a colleague who has a lot of experience in working with these kind of environmental problems. My experience of the home is that repairs and refurbishment are always done, but the timeframe is not always within the managers control. The home does have some incontinence laundry. Staff wear plastic gloves when handling laundry. The washing machine has a high temperature wash and laundry does not have to be carried through the kitchen. The flooring in the laundry area is impermeable. Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Staff are carefully recruited and are competent, trained and qualified. Staff are well supported but there is a shortfall in supervision. EVIDENCE: The home is mostly staffed with permanent members of staff and some know the service users very well. Recruitment practice is sound and training is adequate. There was a shortfall in supervision practice. Currently there are nine staff at the home in addition to the manager. There are two staff on maternity leave and gaps in the rota are covered by bank staff. The manager stated that four staff have NVQ 2 and two are currently undertaking NVQ 3. Two staff have Learning Disability Award Framework (LDAF). The manager is undertaking the Registered Managers Award (RMA). Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 21 I viewed three staff files, covering the keyworkers of the two indivuals being case tracked. The recruitment information is held in the human resources department but the manager keeps a list. I noted that all staff had Criminal Records Bureau (CRB) checks, however on staff member had a check which had been done in 2003. This would pre-date the inception of the Protection of Vulnerable Adults (POVA) register. The manager checked with his Human Resources department and this member of staff has not had a POVA check. They have agreed to seek these for all staff whose CRBs pre-date the list, and have also said that they will re-do their CRB checks. The manager must ensure that all staff have a POVA check (a requirement has been made). The three staff members whose files I viewed, had all undertaken or refreshed basic training in food hygiene, infection control, fire, first aid, and safeguarding adults. The manager stated that almost all the staff have undertaken their basic training. There was evidence on file that staff are given a Performance Development Review, also that they are supervised. However on one file it was apparent that the rate of supervision has fallen well below the standard of six supervision sessions per year. This member of staff is supervised by the deputy manager. During the morning of the inspection it had come to light that a service user had missed an appointment due to a staff member failing to check the diary. He had gone off to an activity instead. I asked the deputy manager if this would be addressed with the staff member in supervision and she said it would. Obviously if supervision is not happening an opportunity to address capability issues and monitor performance in a formal way is lost. The manager must ensure that all staff are supervised at regular intervals, not less than six times per year (a requirement has been made). Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Service users experience good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The service is well run, service users views are sought and taken into account. The health and well being of service users is safeguarded. EVIDENCE: I believe there has been a significant improvement in the running of the home over the last few months. There has been a period of management stability with a permanent manager and a deputy in place. As mentioned before the home is now well structured with staff having a clearer understanding of what is expected of them. . The manager had a firm grip on every aspect of the home and could answer all my questions fully. Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 23 The documentation in the home has improved greatly and is now accessible. Systems for medication and money management are reliable and records are well kept. I was impressed at the way the manager, deputy and staff interacted with service users. They were respectful and used a consistent approach which diffused situations and helped service users to manage their anxieties. The home and the organisation have a number of ways of eliciting the views of service users and assuring quality. There is a regular monthly tenants meeting and annual service user interviews. Service users are interviewed by managers from other homes. There are also Person in Charge (PIC) visits where the home is visited by an Outward manager who makes various checks. As discussed the manager and I feel that service users will become more forthcoming in expressing their views as the improved stability and security of the home supports them. I checked a number of safety records to ensure that the health, safety and welfare of the service users are protected. The home has a fire assessment and staff and service users undertake fire training. There is a fire evacuation procedure in words and a version with pictures. A test of the alarm systems is done every week and a record of fire drills is kept, the most recent being in January 2008. One of the residents is demonstrating some reluctance to descend stairs at night. The manager must arrange a fire drill at night to see if this resident will follow the evacuation procedure successfully (a requirement has been made). The water temperature in taps is checked regularly and a record kept to show that they are in a safe range. The refrigerator and freezer temperatures are also checked and recorded. I looked at the arrangements for the storage of Control of Substances Hazardous to Health (COSHH), and the information kept on them. The substances are kept in a locked cupboard. Information sheets are kept about them. However it was agreed that out of a very thick file it might be difficult to locate the right information quickly if an accident occurred. The manager agreed to sort the file out and ensure that the current and relevant information is clearly labelled (a recommendation has been made). Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 x 26 x 27 X 28 29 30 3 3 x 3 x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000022846.V361673.R01.S.doc 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Portway (200) Score 3 3 3 x 3 x 3 x x 3 x Version 5.2 Page 25 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 15 (1) Requirement The manager must demonstrate that service users have been consulted in the preparation of their care plans, either by obtaining their signature or adding a statement which describes their involvement. Plans must be dated to facilitate regular review. The manager must ensure that all risk assessments are dated. The manager must ensure that the home has an uninterrupted supply of electricity. The manager must ensure that all staff have a POVA check. The manager must ensure that all staff are supervised at regular intervals, not less than six times per year. The manager must arrange a fire drill at night to see if all the residents will follow the evacuation procedure successfully. Timescale for action 01/06/08 2. 3. 4. 5. YA9 YA24 YA34 YA36 13 (4) (c) 16 19 18(2) 01/06/08 01/05/08 01/06/08 01/06/08 6. YA42 23(4) 01/06/08 Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 26 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 YA9 YA9 YA34 Good Practice Recommendations The manager should ensure that service users sign their own assessments where possible, or a statement is added to describe the level of service user involvement. The manager should ensure that old risk assessments are either archived or labelled as such. The manager must ensure that all staff have a POVA check. Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Contact Team Caledonia House 223 Pentonville Road London N1 9NG 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 Portway (200) DS0000022846.V361673.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!