CARE HOME ADULTS 18-65
Upfield (1) 1 Upfield Horley Surrey RH6 7JY Lead Inspector
Deavanand Ramdas Unannounced Inspection 19th December 2006 15:30 Upfield (1) DS0000013441.V320264.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 Upfield (1) DS0000013441.V320264.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. Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Upfield (1) Address 1 Upfield Horley Surrey RH6 7JY 01293 782396 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) Gresham Care Mrs Susan Mary Mallett Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Upfield (1) DS0000013441.V320264.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 -45 YEARS 19th January 2006 Date of last inspection Brief Description of the Service: Upfield is registered with the Commission for Social Care Inspection henceforth referred to as the CSCI to provide accommodation and care to six service users with a learning disability. The home is located in a residential area close to public amenities and other facilities with the accommodation on two floors comprising of an office, kitchen, lounge, dining area, laundry room, bathrooms, toilets, showers and six single bedrooms. The home has a garden which is secure and accessible with private parking available. The range of fees charged by the home is £1352.00 to £1916.00 The manager is Mr. Dominic Wayland to be registered as manager with the CSCI. Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes site visit by the CSCI as part of the key inspection process and carried out by Mr. D. Ramdas. The site visit commenced at 15.30hrs and finished at 20.30hrs and included a tour of the premises, interviews with staff and service users, and a review of documents and care records. The inspector noted service users at the home have communication difficulties and judgements were made about them based on their mood, behaviour and information given by staff. The inspector would like to thank the manager, staff, service users, a relative and the GP for their contribution to the inspection. What the service does well:
The home has appointed a manager to provide management stability, leadership and direction to the staff team. During discussions a member of staff stated ‘‘the manager is making changes for the better and every change is being discussed with feedback from the staff team’’. The home’s service user guide is good and includes the range of fees charged by the home. The inspector noted information is in a widget format (a method of communication) using pictures and symbols to make the information understandable to service users. Activities at the home are well planned and organised and reflect a range of valued and fulfilling activities. The inspector noted service users attended a local college to do maths, food preparation and IT skills training and records indicated service users did voluntary work in the community. During discussions a member of staff stated ‘‘service users have enough activities throughout the week’’ and a service user indicated ‘‘I go to college to do maths and catering’’. The home had person centred plans and health action plans to meet the needs of service users. It is indicated in a comment card completed by the GP ‘‘staff demonstrate a clear understanding of the care needs of service users’’. Recruitment and vetting practices are excellent and safeguard the welfare of service users. During discussions a service user confirmed ‘‘staff are fine’’. The home had good quality assurance measures and used questionnaires to obtain feedback about the home. Further evidence confirmed the home had regular Regulation 26 (monitoring visits) to ensure the safety and welfare of staff and service users. Meals at the home are good and offer variety and choice with health eating options. During discussions a member of staff commented ‘‘meals are well balanced, we do a varied menu’’ and a service user indicated ‘‘food is nice, I like Chinese and stir-fry’’. Information in the home including weekly menu plans is in a widget format to make it understandable to service users to promote decision-making and participation in the home. The home values equality and diversity and promotes the independence of service users. The inspector noted the home had an agreement with a local
Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 6 company for service users to distribute newspapers to local residents to promote community links and social inclusion. A quality assurance questionaire completed by a neighbour dated March 2006 indicated ‘‘no problems with the home, staff or service users’’. Further evidence confirmed the home had employed staff with an African ethnicity to meet the cultural needs of service users. The complaint process is good and during discussions a member of staff stated ‘‘if you have any queries around the house you approach the manager’’ and the deputy manager remarked ‘‘policies are discussed at the deputy manager’s meetings on a monthly basis’’. The inspector noted no complaints were recorded about the home and no matters under safeguarding adult procedures since the last inspection by the CSCI. The home is committed to staff training and development and during discussions a member of staff stated ‘‘we never have any trouble with training’’. What has improved since the last inspection? What they could do better:
The registered manager needs to submit an application for registration as manager to ensure service users benefit from a well run home. The home needs to strengthen staff training including training in infection control, safeguarding adults and NVQ to safeguard the welfare of service users. The home must produce a development/refurbishment plan with timescales and review the arrangements for the management of clinical waste to safeguard the welfare of staff and service users. A fire safety risk assessment must be undertaken by the home to promote health and safety and induction records must be dated and signed by the employee and named supervisor to ensure the joint needs of service users are met by appropriately trained staff. The home shall consider ensuring menu plans have input from a dietician to meet the nutritional needs of service users and future induction programmes need to reflect Skills for Care common induction standards to promote good practice in the home. Upfield (1) DS0000013441.V320264.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. Upfield (1) DS0000013441.V320264.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 Upfield (1) DS0000013441.V320264.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service user guide are good ensuring prospective service users have up to date information on which to make decisions about admission to the home. The arrangements for care planning are good ensuring prospective service users’ needs are assessed before admission to the home. EVIDENCE: The home had a statement of purpose and service user guide written in plain English, nicely presented and in a widget format (a method of communication using pictures and symbols) to make the information understandable to service users. The inspector noted information in the service user guide included the range of fees charged by the home. The home had a policy on assessing the needs of service users and the manager commented prospective service users would be admitted to the home following an assessment of needs. A review of records confirmed the home had a pre-assessment form including a proposed care plan which covered personal care, health needs and social support. The inspector noted evidence of joint care assessments with the manager and general manager of the company involved in carrying out assessments to safeguard the welfare of service users. Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 10 Upfield (1) DS0000013441.V320264.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&9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The arrangements for care planning are good ensuring the needs of service users are identified and met by the home. Decision making in the home is good ensuring service users make decisions about their lives and assistance as needed. The systems for risk taking are good and promote the independence of service users. EVIDENCE: The manager stated the home had individual care plans and a review of records confirmed the home had person centred plans drawn up with the involvement of staff, service users and relatives. A review of records confirmed care plans included management guidelines for service users likely to be aggressive with person centred plans regularly reviewed to reflect the changing needs of service users. The home enabled service users to make decisions about their lives with assistance as needed, and one service user had an advocate to promote rights.
Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 12 Further evidence confirmed individual choices made by service users were recorded and reflected in the menu plans, activity schedules and care plans. The home has introduced a comments book for service users to promote participation and decision making in the home. Due to the nature of service users disability the manager is of the view that service users’ meetings are not appropriate at this point in time. The manager stated the home had a policy on risk taking and a review of records confirmed the home had risk assessments which were dated and signed by staff. Further evidence confirmed risk assessments promoted independence in the areas of personal care and the use of the homes transport for community access. The deputy manager commented staff have risk assessment training covered in LDAF (Learning Disability Award Framework) to minimise identified risk and hazards, and the home had general risk assessments pertaining to the environment to promote safety. It is indicated in a comment card completed by the GP ‘‘staff demonstrate a clear understanding of the care needs of service users’’. Upfield (1) DS0000013441.V320264.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): 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 arrangements for education and occupation are good ensuring service users participate in valued and fulfilling activities. Community links are good ensuring service users are part of the local community. The systems for relationships are good ensuring service users maintain family links and friendships. The daily routines are good ensuring service users’ rights are respected in their daily lives. Meals at the home are good and offer variety and choice. EVIDENCE: The home had a weekly activity programme for service users which reflected valued and fulfilling activities. A review of records confirmed service users attended local colleges to do maths, food preparation and IT skills training and the home employed a placement officer to find paid and voluntary work for service users. Further evidence indicated service users did voluntary work in
Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 14 the community and distributed newspapers locally to promote community links and social inclusion. During discussions a service user commented ‘‘I go to college to do maths and catering’’. The home has it’s own transport for community access and a review of records confirmed service users visited the local shops, pubs and leisure facilities. Further evidence confirmed service users went for walks to the local park and the home maintained neighbourly relationships. The inspector noted a neighbour had completed a quality assurance questionaire in March 2006 about the home which indicated satisfaction with the home, staff and service users. During discussions a member of staff commented ‘‘service users have enough activities throughout the week’’. The manager stated the home had a visitor’s policy and visitor’s information was available in the service user guide. A review of records confirmed relatives visited the home and service users went home regularly to spend time with family and friends. The home had house rules to promote the independence of service users and three service users have keys to their bedroom doors for privacy. Further evidence confirmed staff addressed service users by their preferred names and interacted with service users. Observations confirmed service users were engaged in preferred activities including jigsaw puzzles, listening to the radio and games. The home had written menu plans which were in a widget format (a method of communication using symbols and pictures) to promote choice. A review of menu plans indicated meals offered variety and choice with healthy eating options. Further evidence in the weekly activity planner confirmed service users help plan and prepare meals with service users from African ethnicity having spicy meals to meet their choices and preferences. Following discussions with the manager a recommendation has been made for the menu plan to have dietician input to ensure it is adequate to meet the needs of service users. During discussions a service user indicated ‘‘food is nice, I like Chinese and stir-fry’’ and a member of staff remarked ‘‘meals are well balanced, we do a varied menu’’. Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 15 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. The arrangements for personal support are good ensuring service users receive personal support in the way they prefer and require. The systems for healthcare are good ensuring service users physical and emotional needs are met. Medication management is good and promote health. EVIDENCE: The home has a schedule of activities reflected in the routine of the home with times for getting up, personal care and meals. Observations confirmed service users had good personal hygiene and were appropriately dressed to reflect their personal choice. Further evidence indicated guidelines in person centred plans for personal hygiene with service users having staff from the same ethnic background to provide care and support. The home had arrangements for health care with service users having access to a local GP (General Practitioner) and input from district nurse, psychiatrist and behavioural support team to meet the needs of service users. Further evidence confirmed service users had health action plans and attended a well man clinic to promote health. Dental, chiropody and optical services can be accessed through the local PCT (Primary Care Trust) or privately as required.
Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 16 The home had a policy on medications and a service level agreement with a local chemist to supply medications to the home. Further evidence confirmed the home kept a record of medications received by and returned to the pharmacy to prevent mishandling of medications with adequate storage of medications. A review of records indicated the home had an audit by a pharmacist with management action taken to meet the recommendations made and medication record sheets were dated and signed by staff. The inspector noted handwritten prescriptions on medication record sheets were dated, signed and witnessed by a second member of staff to promote good practice. The home had a list of names with staff specimen signatures and staff have training in medications to promote health. It is indicated in a comment card completed by the GP ‘‘the home communicate clearly and work in partnership’’. Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. The complaint process is good ensuring complaint information is available to staff, service users and relatives. The arrangements for protection need strengthening to safeguard the welfare of service users. EVIDENCE: The home had a policy on complaints with complaint information in the service user guide. The inspector noted complaint information was in a widget format (a method of communication using pictures and symbols) to make the information understandable to service users. The manager stated the home had a complaint book with no complaint recorded and a review of information at the CSCI confirmed no complaint recorded about the home. During discussions the deputy manager remarked ‘‘policies are discussed at deputy managers’ meetings on a monthly basis’’. The home had a policy on safeguarding adults and a copy of the local authority (Surrey County Council) procedures on safeguarding adults. Further evidence confirmed the home had a whistle blowing policy and staff have training in responding to challenging behaviour and restraint to ensure physical and verbal aggression by a service user is understood and dealt with appropriately. A review of information at the CSCI confirmed no safeguarding adult matters were recorded about the home. Following discussions with the manager a requirement has been made for staff to have refresher training in safeguarding adults to protect service users from harm. During discussions a member of
Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 18 staff stated ‘‘if you have any queries around the house you approach the manager’’ and observations confirmed staff supported service users in line with risk assessments and management guidelines to promote the welfare of service users. Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24&30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for the home’s premises need strengthening to ensure service users have a safe and comfortable environment in which to live. The systems for hygiene need strengthening to prevent the spread of infection in the home. EVIDENCE: The home’s premises are suitable for it stated purpose and is in keeping with the local community. On the day of the inspection the home was clean, nicely presented, well ventilated and free from mal odour. Observations confirmed the standard of décor was satisfactory with good quality furniture and fittings. The provider confirmed future investment in the home to improve the kitchen, laundry and dining room for the comfort and enjoyment of service users. Following discussions with the manager a requirement has been made for a written development and refurbishment plan to be drawn with timescales to safeguard the interest of service users. The garden was well - maintained, secure and accessible to service users.
Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 20 The home had a policy on infection control and a laundry room with a washing machine and dryer. The home had hand washing facilities prominently sited and observations confirmed staff practised infection control measures by washing their hands regularly. A review of records confirmed staff were in need of training in infection control and action has been required in respect of this matter to prevent the spread of infection. Following discussions with the manager a requirement has been for the home to review arrangements for the disposal of clinical waste to safeguard the welfare of staff, service users and the community. Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34&35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for NVQ need strengthening to ensure service users are supported by competent and qualified staff at all times. Recruitment and vetting practices are excellent and safeguard the welfare of service users. Training and development needs strengthening to ensure service users individual and joint needs are met by appropriately trained staff. EVIDENCE: The manager stated the home is committed to staff training and development and the company has an agreement with an approved provider for NVQ training for staff. A review of records confirmed three staff have NVQ training and four staff have LDAF (Learning Disability Award Framework) training. Observations confirmed staff were accessible to, approachable by and comfortable with service users and review of records indicated staff have training in autism, responding to challenging behaviour and restraint to meet the needs of service users. Following discussions with the manager a requirement has been made for an action plan to be drawn up with timescales outlining how the home will meet NVQ training target for staff to ensure service users are supported by competent and qualified staff at all times.
Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 22 The home has a policy on recruitment and retention of staff and the home kept staff recruitment files stored in a locked cupboard to promote confidentiality. A review of records confirmed staff have completed application forms, written references, statement of terms and conditions, job descriptions, health questionnaires, training records, personal details and CRB (Criminal Record Bureau) disclosure information to safeguard the welfare of service users. The inspector noted staff recruitment files were in good order and information about recruitment was easily accessible for auditing. The manager stated the home had induction and foundation training and the company had a dedicated training budget. A review of induction records confirmed staff training was linked to service users’ needs and covered statement of purpose, document and records, policies and procedures, and legislation. Following discussions with the manager a requirement has been made for induction records to be dated and signed by the named supervisor and employee. In addition a recommendation has been made for future induction to reflect Skills for Care common induction standards to ensure service users joint needs are met by appropriately trained staff. During discussions a member of staff stated ‘‘we never have any trouble with training’’ and a service user commented ‘‘staff are fine’’. Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for the day- to- day management of the home need strengthening to ensure service users benefit from a well run home. The systems for quality assurance are good ensuring service users, relatives and stakeholders participate in the running of the home. Health and safety needs strengthening to promote safe working practices. EVIDENCE: The home has appointed a manager who provides management stability, leadership and direction to the staff team and is in the process of registration with the CSCI as registered manager. The manager is currently doing the RMA (Registered Manager Award) and is aware of his role and responsibilities. Further evidence confirmed the home had a management structure with clear lines of communication and accountability and during discussions a member of staff stated ‘‘the manager is making changes for the better and every change
Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 24 is being discussed with feedback from the staff team’’. Following discussions with the manager a requirement has been made for an application for registration to be submitted to the CSCI to ensure service users benefit from a well run home. The home had a policy on quality assurance and used questionnaires to obtain feedback about the home from service users, relatives and stakeholders. A review of records confirmed a survey was carried out in March 2006 and the findings available at the home for information. Further evidence indicated the provider carried out regular Regulation 26 (monitoring visits) with appropriate management action taken to safeguard the welfare of the home. The home had a policy on health and safety and staff have training in health and safety, fire safety, basic food hygiene and first aid. Further evidence confirmed the home had a current gas safety certificate and service inspection reports for fire equipment, small portable appliances and emergency lighting. Observations confirmed the kitchen appeared clean and hygienic with fridge and freezer temperatures within normal limits to promote food safety. The home had information about health and safety displayed in the home and a policy on COSHH (Control of Substances Hazardous to Health) to promote safety. Following discussions with the manager a requirement has been made for the home to undertake a fire safety risk assessment to safeguard the welfare of staff and service users in the home. Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 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 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 2 33 x 34 4 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 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 3 x x 2 x Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA23 Regulation 13(6) Requirement The registered person must ensure staff have refresher training in safeguarding adults to protect service users from harm. The registered person must do a written plan with timescales to outline refurbishment work to be undertaken in the home to safeguard the interest of service users. The registered person must ensure the home has an up to date fire safety risk assessment to promote the health and safety of staff and service users in the home. The registered person must ensure staff have training in infection control to prevent the spread of infection in the home. The registered person must review the arrangements for the disposal of clinical waste to promote health. The registered person must do an action plan to outline how the home will meet staff NVQ training targets to ensure service users are supported by competent and qualified staff at
DS0000013441.V320264.R01.S.doc Timescale for action 01/03/07 2 YA24 12(1)(a) 10/01/07 3 YA24 13(4)(c) 10/01/07 4 YA30 13(3) 01/03/07 5 YA30 13(3) 10/01/07 6 YA32 18(1)(a) 10/02/07 Upfield (1) Version 5.2 Page 27 all times. 7 YA35 18(2)(b) (i) The registered person must ensure the homes induction records are dated and signed by the employee and the named supervisor to ensure service user’s joint needs are met by appropriately trained staff at all times. The registered person must ensure an application for registration is submitted to the CSCI to ensure service users benefit from a well run home. 10/01/07 8 YA37 7 20/02/07 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 Refer to Standard YA17 YA32 Good Practice Recommendations The registered person shall consider ensuring the menu plan have input from a dietician to meet the nutritional needs of service users. The registered person shall consider ensuring future induction programmes reflect Skills for Care common induction standards. Upfield (1) DS0000013441.V320264.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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
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