Inspection on 18/10/05 for 10 - 11 Rowan Close

This inspection was carried out on 18th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

10 - 11 Rowan Close 25/07/07

10 - 11 Rowan Close 20/04/06

10 - 11 Rowan Close 14/12/04

10 - 11 Rowan Close 28/06/04

10 - 11 Rowan Close 01/03/04

10 - 11 Rowan Close 28/04/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 10 - 11 Rowan Close Pilands Wood Bursledon Southampton Hampshire SO31 8LF Lead Inspector Annie Billings Unannounced Inspection 18th October 2005 11:00 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 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 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 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. 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 10 - 11 Rowan Close Address Pilands Wood Bursledon Southampton Hampshire SO31 8LF 023 8040 7870 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) MacIntyre Care Mr Matthew Reeves-Smith Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the category LD may only be admitted between 18 40 years of age. 31st May 2005 Date of last inspection Brief Description of the Service: 10-11 Rowan Close is managed by Macintyre Care, and is registered to provide residential accommodation for six service users with learning disabilities. Comprising of two adjoining bungalows that mirror each other in size and layout, the home is accessible to wheelchair users and has been adapted to provide low kitchen surfaces, lowered light switches, specialist baths, moving and handling equipment and wide doorways. A sensory and herb garden have been established to one side of the property, with a patio and lawned area on the other. The home is located in a residential cul-de-sac, and is within 100 metres of local shops, a community centre and a church. The service also provides an unmarked minibus to provide transport for service users. 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5.5 hours and was the second inspection of the year April 2005 to March 2006. Many of the core standards were inspected during the previous visit on the 31st May 2005, therefore referral to both reports will give a full overview of the service. A partial tour of the premises took place and care and other records were inspected. The inspector met all of the residents, and observed their interaction with staff, although due to the communication needs of residents was unable to seek their views on the service. Discussions were also held with three staff members. The registered manager of the service was available for part of the inspection. Five issues were raised as a result of previous inspections. One has been addressed and three have been partially addressed, although one of these was fully complied with the following day, and has therefore not been repeated. It is disappointing that timescales for action given in the previous report, and dates agreed within an action plan from the provider have again not been adhered to. Further delays may result in the Commission taking action to ensure compliance. What the service does well: What has improved since the last inspection? A new recording system has been introduced, to monitor all aspects of health and care needs, nutrition, weight, seizure charts and activities. These are to be used at monthly reviews, to monitor the effectiveness of care plans in meeting the objectives set. Each resident has been appointed two link-workers, to ensure they receive consistent care, and improve communication and recording. 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 6 A programme of communication training has commenced. Five of fourteen staff have undertaken training in alternative methods of communication, and plans are in place for remaining staff to be trained once specialist assessments have been undertaken in November. Fire safety training was undertaken by the majority of staff in July, with a further course already booked for December. A fire drill was also undertaken. The sensory room has been decommissioned ready for decorating, and staff have been busy organising fund raising events to provide new sensory equipment, including a musical waterbed. What they could do better: The risk assessment process needs to be further developed to ensure that action is taken to minimise any identified risk to residents. Staff do not receive training or guidance on the action to be taken in the event of epileptic seizures. The registered manager must put these in place immediately, as this puts residents at potential risk. Despite various consultations with the owners of the property, the main kitchen is in such a poor state of repair that it has since been decommissioned. This must be addressed urgently, as it is restricting facilities available to residents. Many areas of carpet remain badly stained, despite the purchase of a new carpet cleaner. These carpets need to be replaced to ensure the home remains in good decorative order. A staff member has recently introduced a puppy to the home, with the approval of the manager. This has been done without proper consultation of the residents, staff, environmental health or consideration of health and safety and infection control issues. This has been discussed with the manager, and the puppy has since been removed. Hedges and pathways again require attention, as these are restricting access around the home. Several pieces of furniture and equipment were found to be out of action. These must be replaced to ensure that residents are safe and comfortable. Following previous inspections, the provider was requested to ensure that staff receive training in challenging behaviour. Assurances were given by the manager that the resident group did not present challenging behaviours. Records seen at this inspection suggest otherwise, and staff training is to be organised to ensure that staff have the necessary skills. 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 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. 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 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 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards have not been inspected. EVIDENCE: 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards have not been inspected. EVIDENCE: 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14; 16 Residents are able to engage in a range of activities in the home and the community, promoting their rights, independence and choice. EVIDENCE: Activity programmes have been developed for each resident, based on their interests and choice. These are currently not in a suitable format for the residents, although the manager has plans to develop these into pictorial format, once specialist communication and sensory assessments have been undertaken in November. The staff work hard to ensure that residents have every opportunity to fulfil their objectives. Arrangements were made recently for one resident and their family to attend a private film showing at a local cinema. These activities are now recorded within an individual daily diary, as recommended at the last inspection. Residents were observed watching TV in their own rooms, or in the communal lounge as they wished, and privacy was seen to be respected, with staff knocking on doors and interacting appropriately with residents. 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 12 Bed rails are in use on five residents beds to ensure their safety. A requirement was made at the last inspection to ensure that written consent had been obtained from the next of kin. Four were viewed at the inspection, and arrangements were made for the family to sign their consent on behalf of the fifth resident the following day. This consent has since been obtained; therefore the requirement has not been repeated. 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The medication practices and procedures in the home do not ensure a safe system of working, or that residents needs will be met. EVIDENCE: All medication is administered by staff, who are currently undertaking a training course with the local pharmacy, who will also assess competency in administration. Medication records were examined, and it was identified that medication is received and stored, although not ordered on the current prescription; medication administration has been altered, without written instruction from the GP, and medication returns are not recorded or signed for. The senior member of staff agreed to make arrangements for urgent reviews of medication and to request an audit visit from the pharmacist to ensure practices within the home are in line with the Pharmaceutical Society guidelines. The inspector also suggested that the home keep a record of all staff signatures, to enable identification on medication administration records, and to request information sheets on all medications administered to enable staff to recognise any contra-indications. Four residents are diagnosed as epileptic, and may require administration of rectal diazepam in accordance with current prescriptions. Only one member of staff and the manager have received appropriate training, and there are occasions when neither are on duty. No procedure has been implemented to 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 14 provide staff with guidance on the action to be taken, if no trained staff are available. Individual risk assessments have not been undertaken, although a generic epilepsy risk assessment was available. This states that all staff must be trained in epilepsy, should be able to distinguish different types of seizure, should know what to do if resident goes into status and should read the care plan. Training records identify that no staff have undertaken this training. One care plan was sampled that states only the name of the medication and the times to be administered, and no guidelines are available to staff to advise what to do in the event of a seizure. An immediate requirement was issued as these shortfalls can potentially put residents at serious risk. The medication policy available to staff was dated November 1998, and does not meet the requirements of the standard, or the Pharmaceutical Society guidelines for administration of medication in care homes. The senior member of staff was advised this could be obtained from the internet. 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The home has a complaints procedure that residents next of kin are aware of, but must ensure that residents have more opportunity to make their views known. EVIDENCE: It is difficult to assess residents’ level of understanding of the complaints procedure, although following recent communication training, the manager intends to develop a pictorial version. The home ensures they have regular contact with next of kin at bi-monthly social events although no advocacy services are currently involved in the home. Regular newsletters, both locally and nationally also refer to the complaints procedure and it’s accessibility. The manager advised that the use of two link-workers with each resident, and specialist assessments should improve communication with residents, although staff members advised they can identify through behaviours, if residents are not happy. An internal investors in care assessment undertaken in October 2004 states that a more formal system of link worker and residents meetings needs to be introduced, it is disappointing that these have not been introduced. It was suggested by the inspector that formalising and recording part of the social events with next of kin and residents may be useful, until such time as advocacy services become available. One complaint from a neighbour this year has been recorded, and dealt with appropriately, although the logbook sampled requires more detail as advised to the manager. 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The standard of maintenance, furniture and fittings does not ensure that residents live in a safe, clean and comfortable environment. EVIDENCE: A tour of the premises identified that little had changed since the last inspection. It is recognised that some areas may be the responsibility of the Housing Association, it remains unclear who is responsible for which areas. Many of the carpets throughout the home remain badly stained, despite the purchase of a carpet cleaner. One bedroom carpet had an unpleasant odour, even with the window wide open. Two electric raiser beds are not working, and a third divan bed is breaking down and has an ill-fitting mattress. Three individual comfortable chairs are broken, and bedroom furniture is in a poor state of repair, with a chest of drawers falling apart, ill-fitting vanity cupboard doors, cracked mirror, broken wardrobe rail, faulty or cracked vanity lights. One kitchen has been decommissioned due to the bad state of repair, with illfitting doors, missing doors, broken cooker and sink unit and fridge not working. This reduces facilities available to residents, as the adjacent sitting area is not being utilised. The other kitchen cupboards are cluttered and untidy as food and utensils from the other kitchen need to be accommodated. The fitted fridge/freezer has remained broken since the last inspection, although 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 17 alternative freezers have been accessed, and the dining room table is badly scratched and needs replacement. A dog cage was observed in the decommissioned kitchen area. A member of staff had introduced a puppy to the home when on shift, with the manager’s permission. Further discussion with staff and management identified this had been agreed without proper consultation of the residents, staff, environmental health or consideration of health and safety, infection control or food hygiene. The Commission have since been advised that alternative arrangements have been made and the puppy has since been removed. Bathrooms and WC’s are in reasonable condition, although the WC in one bathroom has a leak, and arrangements were being made to replace this. Replacement tiles have been fitted in one bathroom by the Housing Association, although they do not match the colour or size of the existing. The communication system purchased to allow staff to summon help in an emergency has been out of action for two months, and has not been replaced. This could potentially put residents at risk, as staff in other areas could be unable to hear if a staff member was calling for assistance. The sensory room had been cleared, ready for redecoration and staff advised they are planning to hold several fund raising events to provide additional sensory equipment, including a musical waterbed. The laundry room floor is coming away by the back door, and cupboards in this area are dirty and disorganised. The senior member of staff advised that a new cleaning rota had recently been developed to address this, to ensure that each member of staff takes responsibility for certain areas. This will be further monitored at the next inspection. The second laundry was reasonably clean, although it was noted that the file of cleaning products information for the control of substances hazardous to health was inaccessible on top of the medication cupboard. All areas of the garden and pathways are overgrown and look uncared for. One area contained a bicycle, erected tent two paddling pools collecting water and the side gate latch was broken and could not be secured. An unusable swing remains in the back garden and the barbecue remains inaccessible to residents. 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35 Although some progress has been made in updating mandatory training, staff are not sufficiently trained to meet the individual and joint needs of residents. EVIDENCE: From observation and discussion with staff members, they have built good relationships with residents and have a good understanding of their behaviours. One new member of staff said “Rowan is the best home I’ve worked in, as we can spend quality time with the residents”. Since the last inspection, some progress has been made in providing staff with training, although new training records in place still identify shortfalls in staff undertaking mandatory training and training specific to residents needs, and one record was missing. Records identify that five of fourteen staff have received training in food hygiene, ten in first aid, thirteen in fire safety, four in communication, ten in moving and handling, and one in infection control. No evidence of training in epilepsy was available, and the manager advised that he and one other member of staff were training to administer rectal diazepam and suppositories. Seven staff attended training in the protection of vulnerable adults in May, and four have undertaken training in person centred planning. All staff are currently undertaking training in the safe handling of medication with the local pharmacist. These shortfalls must be addressed urgently, as the lack of appropriate risk assessments, specialist medication issues and 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 19 communication difficulties do not ensure that staff have the appropriate knowledge to meet the residents’ needs. All new inexperienced staff undertake a Certificate in Working with people with Learning Disabilities, before moving on to National Vocational Qualifications. Three are currently undertaking NVQ3, one has been achieved and the registered manager is undertaking NVQ4 registered managers award. Staff members spoken with said that they are regularly supervised, and felt supported by the management. 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The management of the home appears disorganised and inefficient. The quality assurance system needs to be further developed and shortfalls in risk assessment, training and detailed guidance to staff does not promote and safeguard the health, safety and welfare of residents. EVIDENCE: The registered manager has been in post since May 2004, and is currently undertaking NVQ4 registered managers award, due for completion in 2006. Discussion with the manager evidenced a number of training courses recently undertaken, to update and expand their knowledge. The management of the home appears disorganised and inefficient. Although recording systems are improving, some records remain disorganised, with out of date policies made available to staff, maintenance issues not dealt with promptly and shortfalls identified by both internal assessments and outside agencies not being addressed. 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 21 Systems are in place to review and monitor the service, although there is little evidence that action has been taken to address shortfalls identified. The manager advised that feedback is sought from relatives, but the quality assurance system needs to be formalised and expanded to involve the residents and other professionals. Environmental Health visited the home in February 2005, and identified a number of shortfalls, particularly relating to environmental risk assessments. Few of these appear to have been addressed. The health and safety policy available in the office is dated December 2004, and the copy available to staff dated 2001. Neither copy has been reviewed since this visit, and must be updated. It is understood that a health and safety person has been appointed, and has recently undertaken training to ensure their competency in this area. Health and safety does not appear to be a priority as risk assessments in place in respect of areas of risk are incomplete, inappropriate as a group or not adhered to e.g. epilepsy, moving and handling, driving the bus. A requirement has been made to ensure that those undertaking risk assessments receive appropriate training. Since the last inspection, fire safety training has been provided to all but one member of staff, one drill has taken place, and a further course has been booked for December. Other records of fire checks identified that fire alarm checks are not always undertaken on a weekly basis. The manager has agreed these will be undertaken in future. Shortfalls in infection control, food hygiene, moving and handling, communication, challenging behaviour, first aid and epilepsy training already identified throughout the report do not ensure that staff have the appropriate training to meet the needs of the residents, and to ensure their safety. The accident book sampled identified action to be taken by the manager. An incident on the 1st April relates to a resident being put in the wrong wheelchair. The action plan suggests the manager was to investigate but there was no evidence that this action had been taken. Another accident on the 27th April details action by the manager to undertake a risk assessment. This was not in place. 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 1 X X 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 10 - 11 Rowan Close Score X X 1 X Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X 1 X DS0000012378.V257315.R01.S.doc Version 5.0 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 Requirement The registered manager must ensure that staff receive training and detailed guidance on action to be taken in the event of an epileptic seizure. Individual risk assessments must be undertaken. Appropriately trained staff are working on each shift and a current medication policy is adhered to. The registered manager must ensure that all equipment in the home is maintained in good working order. (Fridge/freezers; lights, electric raiser beds; communication system) Broken or damaged furniture must be repaired or replaced The main kitchen area must be refurbished. Previous timescale of 30/09/05 not met. Badly stained carpeting in communal areas and bedrooms must be replaced. All staff must receive regular mandatory training in moving and handling, food hygiene, first DS0000012378.V257315.R01.S.doc Timescale for action 18/10/05 2 YA24 23[2]c 30/11/05 3 4 YA24 YA24 23[2]c 23[2]b 30/11/05 01/02/06 5 YA24 23[2]d 31/12/05 6 YA32 18[1]a 31/01/06 10 - 11 Rowan Close Version 5.0 Page 24 7 YA32 18[1]a aid, health & safety, infection control. Staff must receive training in alternative communication methods and challenging behaviours. Some progress has been made but timescale of 31.3.04 and 31.1.05 not met. All those undertaking risk assessments must be trained to do so. The registered manager must undertake generic and individual risk assessments for any area of risk to residents or staff, and must take prompt action to ensure safe working practice. 31/01/06 8 9 YA32 YA42 18[1]a 13[4]c 31/01/06 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 10 - 11 Rowan Close DS0000012378.V257315.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 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. 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