Inspection on 13/02/06 for 10 The Crescent

This inspection was carried out on 13th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

10 The Crescent 07/09/07

10 The Crescent 21/11/06

10 The Crescent 23/06/05

10 The Crescent 17/11/04

10 The Crescent 08/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Crescent, The (10) 10 The Crescent Pewsey Wiltshire SN9 5DP Lead Inspector Alison Duffy Unannounced Inspection 13th February 2006 4:15pm Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 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 Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 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. Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Crescent, The (10) Address 10 The Crescent Pewsey Wiltshire SN9 5DP 01672 562266 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) Landlace Care Homes Ltd Mrs Nanette Lance Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 Brief Description of the Service: 10 The Crescent is a residential care home, which accommodates four service users with a learning disability. The home is one of three residential care homes owned by Landlace Care Homes Ltd. Mrs Nan Lance is the responsible individual and also the registered manager. Mrs Lance undertakes shifts as part of the working roster and also covers additional shifts within the organisation at times of annual leave or sickness. 10 The Crescent is located within a residential area of Pewsey and is within walking distance of local amenities. The property is semi detached and furnished to a good standard. Service users have single room accommodation on either the ground or first floor. There is a spacious kitchen with dining area and a separate lounge. The home has two members of staff on duty throughout the waking day when service users are at home. At night sleeping in cover is provided. Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 13th February 2006 from 4.15pm – 7.10pm. All service users had just shortly arrived back from their day service and two members of staff were on duty with Mrs Lance. Service users were following their preferred activities and a review was also taking place. The inspector spoke with service users and also observed interactions. Communication between all individuals was prominent and a homely, natural environment was portrayed. The mealtime was used as a social occasion and a means to catch up on the days’ events. All interactions appeared respectful and a light-hearted, animated atmosphere within the home was evident. Care planning information, the Statement of Purpose and the management of service users’ money were viewed. Discussion took place with Mrs Lance regarding recent events and it was agreed an additional date would be set in order to address personnel matters. It was therefore agreed that the second part of the inspection would take place on 27th February 2006. Requirements made at the last inspection were discussed with Mrs Lance during the visit of the 27th February 2006. This took place between 1pm and 4.30pm. During this time, discussion also took place with support workers, Teresa Pound and Steve Black. The inspector met with all service users on their arrival home from their day service. What the service does well: What has improved since the last inspection? Since the last inspection, recruitment documentation has been developed which will significantly improve the amount of information gained. The majority of the staff team have attended first aid, epilepsy, adult protection and food hygiene courses. Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 6 Formal staff supervision has commenced and a new written format has been developed to record all sessions. A monitored dosage system for medication administration has been introduced, which minimises the risk of errors to service users. What they could do better: 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. Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 7 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 Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 8 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): 1 Information about the home is in need of updating in order to ensure that an accurate reflection is portrayed. EVIDENCE: The Statement of Purpose was noted to be in need of review as some of the information was out of date. For example, the document stated that the home is registered for four male service users yet there are currently, one female and three male service users within the home. Training information also highlights that some staff are about to commence their NVQ level 2 yet these staff have now gained their qualification. The most recent staff members have not been added to the documentation. Mrs Lance was therefore advised to review the document and gain guidance from Schedule 1 of the Care Homes Regulations 2001 when doing so. There have not been any new service users to the home since the last inspection. Mrs Lance however has undertaken a detailed assessment of each service user, which is clearly stated within a documented format. Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 9 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): 6 Care plans contain a range of information yet do not identify changing need. The management of challenging behaviour is insufficiently documented which creates a risk to the personal safety of individuals. Daily records are detailed and give a clear indication of the well being of each service user. EVIDENCE: Each service user has a care plan, which details preferred routines, a record of health care provision, risk assessments and review forums. Some care plans had been reviewed, yet one plan in particular did not contain details of recent events. Evidence of changing need and guidelines for staff regarding certain behaviours were therefore unavailable. Discussion took place with Mrs Lance regarding these matters and it was evident that the Community Learning Disability Nurse had been called for guidance and was attending the home on the 28th February 2006. Mrs Lance also reported that she was in the process of updating the plan and developing recording formats for behaviours. Such circumstances however required an immediate update of written information including possible triggers and the most appropriate ways of managing such Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 10 challenging behaviour. During the discussion, the need for procedures and specific risk assessments was agreed. Areas requiring consideration must include restraint, supervision, leaving the home unattended, the refusal of medication, the criteria of ‘as required’ medication and safety whilst travelling. Further areas include the accessibility of harmful items, being in the company of others and out in the community. Another care plan that was viewed contained a range of information that had been agreed by the service user. Epilepsy however had been given a low profile although within later documentation a relatively high number of seizures had been documented. One seizure also resulted in an injury from falling on an item of furniture. Mrs Lance was therefore advised to expand upon information and adjust risk assessments accordingly. Such information should also include action plan points from review meetings. In this instance, having a late night snack to reduce the possibility of having a seizure in the morning was stated although not in the care plan. Within documentation Mrs Lance was advised to ensure consistency. For example, within one file there was a dermatology out patient appointment. There was not however any evidence of the need for this appointment and therefore no guidelines for staff regarding how the problem should be managed. Some files would benefit from the removal of out of date information in order to give priority to prominent matters. Those plans viewed had an up to date photograph. As well as a care plan, each service user has a daily dairy. These provided excellent detail with aspects such as wellbeing, mood, activity, routines and food consumed clearly stated. All accounts were well written and signed appropriately. Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 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 and 15 An increase in staffing levels has enabled greater opportunities to service users both in house and on an external basis. Service users are able to follow their preferred interests and a range of external activity is promoted. Relationships are supported and visitors are made to feel welcome with hospitality evident. EVIDENCE: Within the notice board in the kitchen, a number of forthcoming events were displayed. These included a London Theatre Trip and a Steam Festival in the Isle of Wight. Service users spoke of a recent party and reported that they had a skittles night booked for the following evening. Trips to the cinema, places of interest, shopping and swimming are regularly undertaken. The home has its own transport and since the increase in staffing levels, greater choice is available. With two staff on duty, greater individuality is also available. For example a member of staff can remain in the home if not all service users wish to attend an event. Within leisure time, service users are encouraged to Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 12 socialise and follow their preferred routines. On the first day of the inspection, some service users were watching television in the lounge and in their own room while others were undertaking a jigsaw in the kitchen. Interactions between service users and staff were productive. Lots of discussion was evident and the home in general was animated with a domestic style atmosphere. Mrs Lance reported that staff aim to enhance quality of life and therefore give service users something to look forward to. As part of this, holidays are important aspects. Service users are able to choose their destination and go with staff either on an individual basis or as a small group. All service users’ going away together is not promoted due to varying interests. It was reported that one service user would be going to Spain with Mrs Lance during March. All others have destinations planned. Service users have developed friendships with others within Landlace Care Homes and also through their attendance at day services and external clubs. Social interaction is therefore promoted and personal friendships are supported. Staff ensure privacy and are discreet and respectful when service users, within a relationship, wish to spend time together. Family contact is promoted and service users are able to receive visitors within their private accommodation or communal areas. Opportunities for personal development were not assessed on this occasion. It was noted however, that various systems are beginning to be developed in order to increase awareness, interaction and involvement. For example, one service user now has a photo board that prompts the activities of the day through pictures. A staff photo board detailing the members of staff on duty is also displayed in the kitchen. Mrs Pound reported that since the staffing increase, service users are able to assist with the food shopping and spend greater time assisting with housekeeping tasks such as meal preparation. Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 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 A recent change in the system for medication administration, reduces the risk of error to service users. Medication systems are well managed yet guidelines for ‘as required’ medication are required to ensure a consistent approach. EVIDENCE: Since the last inspection, a new monitored dosage medication system has been introduced. The pharmacy dispenses the ordered medication and provides printed medication administration sheets. Although within its early stages, the system appears to be working well. On the first day of the inspection it was noted however that a large amount of medication was in need of disposal. This had been undertaken by the second day of the inspection. Service users do not self medicate yet are fully informed of the medication they take. For example one service user has ‘as required’ medication for anxiety. The service user is always asked if a tablet is required when symptoms are noted. In this instance Mrs Lance was informed of the need to state specific guidelines for ‘as required’ medication usage, within the service user’s plan of care. A number of staff have completed an in depth medication course and printed sheets of all medication are available for staff reference. Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 14 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 and 23 Complaint information is readily accessible to service users and their family/representatives. Greater protection is afforded to service users as the majority of staff have now undertaken adult protection training. Shortfalls within the system of managing service users’ personal money and insufficient policy guidance, place service users at risk of potential mismanagement. EVIDENCE: The home has a copy of the complaints procedure displayed in the hallway and there is also a copy within each service users’ care plan. At the last inspection, comment cards demonstrated that some families were not aware of the home’ complaint procedure. Mrs Lance has since forwarded a copy to all individuals. CSCI has not received any formal complaints about the service. At the last and previous inspection a requirement was made to ensure all staff have adult protection training. An in house training package has been purchased and a number of staff have viewed such. This does not apply however to the whole staff team. Mrs Lance was informed of the need to give this priority and reported that all would be completed within the next two weeks. Mrs Lance reported that the training package also comes with questionnaires to evidence the staff members’ learning. It was agreed that these should be completed and staff should also sign to demonstrate their understanding of the subject. Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 15 Within care planning information, body charts are used to evidence any signs of bruising. A chart is in place for each month and some have been completed. Staff are required however to stipulate when the bruise was actually identified although a chart is not necessarily needed for each month if there is nothing to report. An investigation of the possible reasons for the bruising should be clearly stated within written documentation. Within the kitchen it was noted that a listening device is used in order to promote the safety of those service users with epilepsy. While the reasons for this are acknowledged Mrs Lance was informed of the need to gain written consent of such from the service user and their care manager. At the last inspection a requirement was made to review and regularly monitor the management of service users personal monies. In response to this, Mrs Lance asked for two staff signatures or the service user’s signature to demonstrate authorisation of transactions. All balance sheets were also checked on a weekly basis. Despite this however, a discrepancy was noted at this inspection. Mrs Lance was therefore informed of the need to tighten the system further and ensure that staff count all monies before and after each transaction. Staff must only sign the balance sheet following assurances that all aspects are correct. There was no evidence of service users loaning money to each other as of previous inspections. Receipts are also now being numbered and attached to the current balance sheet. For easier audit purposes, it would be beneficial to remove all old receipts from the cash tin. These should be stored appropriately with old balance sheets. At the last inspection it was identified that the home had an unwritten policy for transport, contributing to gifts and subsidising staff when out. A requirement was therefore made to formalise this and Mrs Lance reported that she had started to develop a format. This must however be given further attention to ensure completion. Transport costs, must also be clearly stated and the reasons for such need to be identifiable. Mrs Lance was also informed of the need to document requirements of additional expenditures within the Statement of Purpose. During the inspection it was evident that two service users had sold their old televisions to staff members for minimal amounts. While it is acknowledged that this is what the service users wanted and their wishes should be respected, Mrs Lance was advised to devise a policy for such situations in order to ensure the protection of both service users and staff. Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 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): While these standards were not assessed on this occasion, the communal areas appeared comfortable, clean and well maintained. EVIDENCE: These standards were not assessed on this occasion. Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 17 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): 33 and 35 The increase in staffing levels, following the accommodation of four service users, has significantly improved flexibility and the availability of social opportunities. As there have been no new staff it was not possible to evidence that recruitment procedures had improved. Mrs Lance gave confirmation however that robust procedures would be followed. Training provision has improved yet some topics remain unaddressed for some staff members. EVIDENCE: There continues to be two staff on duty when service users are at home. At night a member of staff provides sleeping in cover. Mrs Lance often works as part of the working roster and also provides on call provision. Additional staffing is provided at times of specific need. For example, Mrs Lance has recently facilitated double cover at night, following an incident, in order to give additional support. At the last inspection requirements were made in relation to gaining written references and the need for a POVA First check before employment. As there have been no new staff, it was not possible to assess this practice. However Mrs Lance has developed the reference request format, which is much Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 18 improved. Full compliance with all recruitment checks was assured at the time of the next appointment. Through discussion it was evident that following a requirement at the last inspection all staff have now undertaken first aid training. All except one have also completed epilepsy and a number of staff have undertaken food hygiene and adult protection training. Mrs Lance reported that she was aware of the need to ensure all staff complete all topics. Due to a specific need, challenging behaviour training is in the process of being arranged for all staff. Written evidence of the staff members’ attendance within all courses is also required. Mrs Lance was advised to ensure all staff sign to demonstrate this and their learning of the topic. Although not fully assessed on this occasion, it was noted that Mrs Lance has developed documentation for staff supervision and annual appraisals. Formal supervision sessions have recently commenced with Mrs Lance currently undertaking all sessions. It was therefore agreed that supervision training would possibly be useful for some staff, which would give opportunities for sharing the role. Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 19 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): 39 and 42 10 The Crescent is a comfortable, well maintained property. EVIDENCE: The home does not have a formal system for gaining feedback or monitoring care provision. At the last inspection therefore, a requirement was made to develop and maintain a quality assurance system. Mrs Lance has found this area challenging and progress has been slow. In response to this, discussion took place regarding the changing focus of inspection. It was agreed that Mrs Lance should wait until further direction regarding the annual Quality Auditing tool, which all providers will be expected to complete. Since the last inspection Mrs Lance has developed a missing person format, which includes a written description of each service user and an up to date photograph. This system, when fully completed, will be much improved. A number of new risk assessments have been devised although some of the old assessments would also benefit from review. Discussion took place with Mrs Lance regarding the identified incident and the need to ensure all aspects are addressed within the risk assessment process. Mrs Lance confirmed that this Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 20 would be undertaken and such topics would also be discussed with the Learning Disability Community Nurse. The risk assessment process in relation to service users with epilepsy was also discussed. While it is acknowledged that identified service users are not left alone in the bath unattended, such information needs to be documented. A risk assessment should also be in place regarding furniture, as one service user recently suffered an injury during a seizure, through falling on a wicker basket. At the last inspection a requirement was made to address radiators within the risk assessment process. This remains outstanding although Mrs Lance confirmed that covers to radiators would be fitted in identified bedrooms. Since the last inspection, staff have managed situations of a service user leaving the building unattended and incidents of challenging behaviour. Such incidents should have been reported under Regulation 37 although Mrs Lance was not aware of the need to do so. Examples of such were discussed and Mrs Lance reported that she would inform CSCI of any incident in the future. The fire log book contained regular testing of the fire alarm systems. There was no evidence however of a regular fire drill or staff training and the fire risk assessment was in need of up dating. Documentation demonstrated the servicing of the fire alarm systems by external contractors. Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 X 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 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 3 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X X X 2 X X 2 X Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 22 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 YA1 Regulation 4 Requirement Timescale for action 31/05/06 2. YA6 3. YA6 4. YA20 5. YA23 The Registered Person must ensure that the Statement of Purpose is regularly reviewed in order to provide an accurate reflection of care provision. 15 The Registered Person must ensure that care-planning information reflects service users changing needs and provides guidelines for staff as to how to manage certain behaviours. 13(4)(a)(b)(c) The Registered Person must ensure that procedures and risk assessments are in place regarding challenging behaviour and epilepsy in order to ensure personal safety and that of others. Such assessments must be kept up to date. 13(2) The Registered Person must ensure that specific guidelines regarding ‘as required’ medication, form part of the service user’s plan of care. 13(6) The Registered Person must ensure that all staff receive adult protection training. DS0000028316.V285824.R01.S.doc 31/03/06 24/03/06 31/03/06 31/03/06 Crescent, The (10) Version 5.1 Page 23 6. YA23 13(6) 7. YA23 13(6) This was identified at the last inspection and although some staff have undertaken the training, others have not. A revised timescale has been agreed and this must be adhered to. In the event of non-compliance, enforcement action will follow. The Registered Person must 27/02/06 ensure than any identified bruising is clearly documented with the date it was observed and an investigation of its possible cause. The Registered Person must 27/02/06 further tighten the management of service users’ personal monies in order to ensure all transactions are correct. This was identified at the last inspection yet despite added control measures, an error was still noted. The Registered Person must 30/04/06 ensure that a policy is devised regarding the payment of transport, staffing costs when out and the selling of personal items. Any costs must be fully evidenced and all such matters must be stated within the Statement of Purpose. The Registered Person must 27/02/06 ensure that a fully completed application form and two written references are received before a prospective member of staff commences employment. This was identified at the last and previous inspection. It was not possible however to assess on this occasion as there have not been any new 8. YA23 13(6) 9. YA34 19 Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 24 10. YA34 19 staff. Recruitment will be addressed at the next visit. The Registered Person must ensure that a POVA First check is undertaken before a prospective member of staff commences employment. 27/02/06 11. YA35 18(1) (a)(c)(i) 12. YA40 37 13. YA42 13(4)(a)(c) This was identified at the last and previous inspection. It was not possible however to assess on this occasion as there have not been any new staff. Recruitment will be addressed at the next visit. The Registered Person must 31/05/06 ensure that all staff have sufficient training to demonstrate competence within their role. This must include food hygiene, epilepsy and challenging behaviour. A record of all such training must be maintained. The Registered Person must 27/02/06 ensure that any incident, which affects the well being of service users, is reported, in writing to the CSCI without delay. The Registered Person must 31/03/06 ensure that any risk to a service user from a radiator, identified within the risk assessment process, is addressed through the fitment of a cover. This was identified at the last inspection. The Registered Person must ensure that all staff have regular fire training and a fire drill must take place during each three month period. These aspects must be fully documented. 14. YA42 23(4)(d)(e) 27/02/06 Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 25 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. 4. Refer to Standard YA6 YA6 YA23 YA23 Good Practice Recommendations The Registered Person should ensure that documentation regarding services users is consistent in content. The Registered Person should ensure that out of date information is removed from care plans in order for prominent information to be more readily accessible. The Registered Person should ensure that the service user and their care manager give written consent to the use of a listening device. The Registered Person should ensure that all old receipts are removed from service users money tins. This was identified at the last inspection. The Registered Person should ensure that staff have supervision and appraisal training before undertaking the role of supervising other staff. 5. YA36 Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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. Extracts may not be used or reproduced without the express permission of CSCI Crescent, The (10) DS0000028316.V285824.R01.S.doc Version 5.1 Page 27 - 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!