Inspection on 09/01/08 for 117A & B Hitchin Road

This inspection was carried out on 9th January 2008.

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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

117A & B Hitchin Road 17/02/09

117A & B Hitchin Road 16/01/07

117A & B Hitchin Road 07/02/06

117A & B Hitchin Road 16/08/05

117A & B Hitchin Road 07/03/05

117A & B Hitchin Road 07/03/05

117A & B Hitchin Road 07/03/05

117A & B Hitchin Road 07/03/05

117A & B Hitchin Road 30/09/04

117A & B Hitchin Road 30/09/04

117A & B Hitchin Road 30/09/04

117A & B Hitchin Road 30/09/04

117A & B Hitchin Road 01/12/03

117A & B Hitchin Road 01/12/03

117A & B Hitchin Road 01/12/03

117A & B Hitchin Road 01/12/03

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 117A & B Hitchin Road Shefford Bedfordshire SG17 5JD Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 9th January 2008 12:00 117A & B Hitchin Road DS0000015002.V357650.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 117A & B Hitchin Road DS0000015002.V357650.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. 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 117A & B Hitchin Road Address Shefford Bedfordshire SG17 5JD 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) 01462 850022 01462 850689 hftbedfordshire@hft.org.uk www.hft.org.uk Home Farm Trust Care Home 12 Category(ies) of Learning disability (12) registration, with number of places 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2007 Brief Description of the Service: 117 A B Hitchin Road is one of five registered care homes within Bedfordshire managed by Home Farm Trust. HFT are a nationwide provider for people with learning disabilities. The home is situated on the outskirts of Shefford, which has a number of facilities including shops, pubs, restaurants, and a library. The home provides its own transport in the form of two domestic scale vehicles. There is ample parking space, shared with the organisations headquarters/day care facility, which is adjacent to the home. The building has been divided into two units - Once more House and Apple wood House, and provides accommodation for 12 adults with learning disabilities. Each unit has been designed to accommodate six adults, with separate and independent sleeping and communal facilities. Each has its own lounge, dining room, kitchen, bathing and toilet facilities, and individual bedrooms for all service users. There are separate external doors to access each unit, and they are also linked internally, through the upstairs office/staff sleeping in area. Outside, there is a shared laundry room and a large garden. Information relating to the homes range of monthly fees is available. It is included within information provided about the home and individual service users contracts. 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 09/01/08 by Pursotamraj Hirekar over 5 hours 20 minutes. The staff on duty coordinated the inspection. The method of inspection included study of care plans, risk assessments, staff deployment duty rota, relevant care delivery documents, and discussions with staff, conversation with service users’ and partial tour of the building. Letter and documentary evidence received from the service manager, in response to the feedback given on inspection, are included for analysis and preparation of this report as well. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that medicine received and all unused medicine returned on time, and records completed & maintained. The home must ensure that the premises meet the requirements of the local fire services and planned maintenance of decoration is completed as scheduled. The home must ensure that internal monitoring is consistently carried out and records updated on time. The home must ensure that a manager is appointed and application submitted to the commission for registered manager. 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 Page 6 The home must ensure that nutritional assessments are carried out and are reflected in their care plans to evidence dietary needs and choices are considered suitably for each individual service users’ and that is reflected in their daily food menu. The home should revisit staffing levels and deployment, especially for the night shift and make suitable staffing arrangement to prevent any neglect or harm to the service users’ with out further delay. The home should update the records pertaining to staff training needs, trainings undertaken and planned. Arrangements should be made to ensure that service user plans are made available in a suitable format that the service user can understand. 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. 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 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 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 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. 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 were good, providing service users and prospective service users with details of the services the home provides, enabling an informed decision about admission to the home. EVIDENCE: The homes service user guide was available in a suitable format for some of the service users intended and provided information to enable prospective service users to make an informed choice about where to live. Information regarding trial visits was also included within the homes’ service users guide under ‘moving in’ section, describing the benefits and purpose of this. There was evidence that the home had assessed the needs of a prospective service user and demonstrated that the method and system for doing so provided a satisfactory form of assessment. The method of assessment involved the service user, the family, and other individuals referred to as part of the service users care management process. There was evidence that the service users whose lives were tracked had written contracts with the home, which included a statement of the terms and conditions. There was evidence that the home had introduced contracts in a format appropriate for the needs of most of the service users. There has been no new admission since the previous inspection. 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user plans contained satisfactory information. However, the plan could be made available in the suitable format for people using service could understand. EVIDENCE: A sample of the service user’s plans and supporting documentation were examined and found to contain suitable and sufficient information to help meet their changing needs and personal goals were identified and reflected in their individual plan. There was evidence that the plans had been reviewed. In addition annual reviews of the residents needs and subsequent service user plans had been held, which involved the service user, service manager, manager, key worker, family member, reviewing officer and when necessary, advocate. The plan was not made available in a format the service user could understand. It should be noted that as part of the homes approach to develop their person centred planning principles, they have introduced a new service user plan & assessment tool system called ‘spars’, which was in use for 4 service users out of 11, the work was in progress for the rest. 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 Page 10 There was evidence from speaking with service users and records examined that service users were assisted as necessary to make decisions about their daily lives. Staffs were observed communicating in ways appropriate to each individual service user, to enable them to make an informed decision in a way the service user could understand. However, the nutritional assessments were not provided on this inspection and there was no evidence on what basis food menus of people using services were decided. Staff coordinating the inspection appeared unaware of any specific nutritional assessments that were carried out for the service users’. There were risk assessments in place as part of the homes risk assessment strategy to enable service users to take risks supported by staff. Risk assessments examined had been signed by the staff member completing it for example on the 06/02/07 and 30/07/07, in the space provided on the form. 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided satisfactory opportunities for education & social activities. However, further development was needed to ensure nutritional assessments are carried out and are reflected in their care plans to evidence dietary needs and choice are considered suitably for each individual service users’ and that is reflected in their daily food menu. EVIDENCE: The home supported service users to attend college and many were also supported by the home to regularly visit a local resource centre, which provided planned educational and training activities, during the day and evening. There was evidence that the home supported service users to maintain family links and friendships inside and outside the home, in accordance with their wishes. Staff was observed knocking on service user’s bedroom doors before entering and waiting to be invited into their bedrooms. Those service users who wished to be supported to keep their own room keys. Service users responsibility for housekeeping tasks was specified within 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 Page 12 individuals’ service user plans and generally within the homes’ service user guide. On this inspection it was found that lean British beef mince that was dated ‘use by’ 31 December 2007 was kept on the kitchen platform for defrosting for the evening meal of 09/01/2008. When asked, the staff on duty said that the same could be used if kept frozen on the date of purchase and defrosted to use on the same day. The food safety policy statement of the home was seen and found that, there were no reference made to expiry date of food and its consumption. However, following a feedback to the service manager, we received a letter reporting that a local policy for food storage – freezing and defrosting has been written and to be implemented with immediate effect. A copy of the policy was received and found satisfactory. 3 Service users were observed during a mealtime eating plain bread and butter spread. During the feedback, the service manager had mentioned that the service users also had soup along with bread and butter. However, the nutritional assessments were not provided on this inspection and there was no evidence on what basis food menus of people using services were decided. There were no set mealtimes as such, as the service users preferred the flexibility and this also suited their individual evening activities. Service users were observed being supported by staff to clean and tidy up after the meal. 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems for the administration of medication were satisfactory. However, further development was needed to ensure that medicine received and all unused medicine returned on time, and records completed & maintained. EVIDENCE: Service users spoken to said they enjoyed living at the home. There was evidence that service users received additional specialist support and advice from people outside the home such as occupational & speech therapists when needed. Service users appearance reflected their personality, as they were able to choose, some with support, their own clothes, make up & hairstyles for example. There was evidence that the home accessed outside healthcare professionals and services as required; in order to support and meet the healthcare needs of the service users. The home had ensured that care staffs were trained in medication and the procedures implemented suggested that service users safety was being maintained in most areas. Staff observed administering medication to service users appeared competent and confidant. Further development was needed to ensure that medicine received and all unused medicine returned on time, and 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 Page 14 records completed & maintained. One service user was recommended by GP to stop loratadine tabs 10mg, the blister pack was still at the home stored in drawer of a bed in the office/sleep-in room and was not returned along with other medicine on the 07/01/08. One service user returned to the home on 03/01/08 with medicine stock in a bag. On reconciliation, during this inspection the stock mentioned on the mar sheet and the medicine available in stock at the home, the numbers did not tally. However, a separate hand returned record was made available of the medicine that came along with the service user, which actually matched with the medicine administered and the medicine available at the home in stock. We further, received evidence for all medication booked in from hospital signed by 2 staff members. The home had good death and dying policies. The home had discussed service users wishes in the event of terminal care and death; service users family and friends had been involved in planning for this. This information had been documented. 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had appropriate arrangements for protecting service users. This helped to ensure service users were protected from abuse and to feel that they views were listened to and acted upon. EVIDENCE: The home had a satisfactory complaints procedure that ensured service users felt their views were listened to and acted upon. The complaints procedure was produced in a format appropriate for service users to understand and access. The home had a safeguarding vulnerable adults policy in place, which included whistle blowing and staff spoken to demonstrate they were aware of the procedure. Most staff had also attended abuse awareness training, which included SOVA; SOVA training was also included and formed part of the homes induction process for staff. The homes policies and practices regarding service users money and financial affairs were generally satisfactory and protected service users from abuse. 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had made significant improvements to the building since the previous inspection. However, the home needs to complete all the necessary tasks as scheduled. The home was maintained clean and hygienic. EVIDENCE: The home provided a purpose built, environment for service users. The home had developed safe access to its wheelchair using service users, to access from the main road to the home. A ground floor bath side panel was found broken. We have received evidence of the report to the maintenance person that bath panel is now scheduled for fixing by 31/01/08. The toilet on the ground floor, first floor toilet and bath and shower on the first floor were small to support service users’ who may have higher needs, as this would be difficult to manoeuvring with in the space available. This was further confirmed with staff on duty. However, at the time of previous inspection, it appears that, there was one service user who had 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 Page 17 problems of space in the bathroom. This bathroom has been now converted into a walk in shower, also the service user no longer lives at the home. One service user said that they had everything they needed and wanted in their bedroom. Another service users bedroom was observed to reflect their needs and lifestyle. All rooms were single occupancy. Service users spoken to were clearly happy with their individual bedrooms and they had free access to them, one service user said they had chosen the decoration themselves with the support of their family. The home was unable to provide evidence during the inspection regarding the failure and suggested actions taken to remedy those failures as reported in fire safety inspecting officer report of 24/10/2007. However, we have received a response letter with documentary evidence provided by the service manager on the actions taken and proposed meeting with the beds health and safety officers including fire, to confirm the actions taken or any more actions if required, to be taken by the home. The home appeared clean and generally free from offensive odours, service users, care staff and night staff were responsible for ensuring this was maintained. 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 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 staff training were satisfactory. However, further development was needed to ensure that staffs training records are updated regularly. The home should revisit staffing levels and deployment, especially for the night shift and make suitable staffing arrangement to prevent any neglect or harm to the service users’ with out further delay. EVIDENCE: Staff spoken to identify varied training which they had undertaken at the home and this was supported by evidence in their training records. Although there was limited evidence that training in some service users specialist needs had been provided. For example, two service users were diagnosed with dementia, and one service user can get agitated. However, there was insufficient evidence to support adequate staff training to meet service users needs in this area. However, the service manager confirmed in writing that all the mandatory trainings for the staff was provided according to their job role and responsibilities but the training record was unclear to support this evidence. The service manager further confirmed that staff training on dementia has been planned to be completed by end of April 2008.The home should update the training records to avoid any potential confusion. 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 Page 19 The percentage of staff qualified at NVQ (national vocational qualification) level 2 or 3, was just the minimum required level of 50 , the home was aware of the preventative measures with regard to staff turnover and consequences of any subsequent shortfall of staff with NVQ 2 qualification and therefore, further training was underway, the service manager confirmed. The home operated on a 3-shift model morning, evening, and night. The morning shift had 5 staff, evening shift had 3 staff, and night shift had 1 sleepin staff. On the day of this inspection, there were 11 people using services were living in 2 different buildings, each building had separate kitchen, lounge, and bathrooms. Of these 11 people using services, 2 service users had high needs with dementia, 1 service user with high needs had one false eye and 20 vision in other eye, 1 service user had high needs and was full blind, 1 service user had high needs and can get agitated, 1 service user had medium needs and was non verbal and 5 service users had low level of needs. 1 service user who had high needs gets up in the night and wanders around. Another service user with high needs gets up in the night to use the toilet and could stay there whole night when he hears loud noise. Staff wouldn’t know till the morning because there was no waking staff member on duty. The only staff member on duty is a sleep-in staff. The sleep-in room is the office - cum sleep in room on the first floor, which connects both the buildings. This service user uses a night lamp on for the whole night, to prevent him from banging the door in the night. The staff members on duty confirmed, this evidence as well. In response to the feedback, the service manager in her letter had mentioned about one service user, the home do not consider the risk at night to be acceptable, and was in discussion for additional staff support with the social services. The home should revisit staffing levels and deployment for the night shift and make suitable staffing arrangement to prevent any neglect or harm to the service users’ with out further delay. The service manager further confirmed during the discussion that the home always respond to day-to-day situations and increase levels of support when necessary during day time as well. Staff spoken to provided evidence that staff received regular supervision. 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home should ensure to make an application for the registered manager with the commission. The home should ensure that the internal monitoring is carried out regularly and records updated on time. EVIDENCE: The registered manager has now resigned and the post has been advertised. In the interim, acting manager will continue, with the support from assistant service manager and service manager. On this inspection the acting manager and the senior carer were off from duty, and the support workers on duty managed the home. However, the service manager was available in the adjacent building – the resource centre, if required. The support worker coordinated the entire inspection and they appeared to have good understanding of their roles and responsibilities. Staff was observed to communicate effectively with service users and appeared approachable. Service users who were spoken to supported this view. The home had an 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 Page 21 inclusive atmosphere. The home had made an application to vary the conditions of registration to include 2 service users with dementia. The home had developed a quality assurance and monitoring system, from which the home had developed an action plan from the information it had collected from several sources. There was evidence that the home had begun a cyclical system of regularly monitoring and reviewing service users views, amongst others. The internal monitoring mechanism was structured in a way, which was aligned with the national minimum standards and detailed the current practice, targets for 2007, and status. This document was seen on this inspection and found that, it has not been updated, to reflect the current status. In response, to the feedback to the service manager, we received a letter from the service manager reassuring that the records shall be updated to ensure, that the home evidences that progress is checked and that work is still ongoing if the action is not achieved. Various records were examined to support adequate compliance with the following safe working practices, regarding health & safety. 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 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 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 Page 23 No 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 (2) Requirement Timescale for action 31/01/08 2. YA24 23 3. YA33 18 The home must ensure that medicine received and all unused medicine returned on time, and records completed & maintained. The home must ensure that the 31/01/08 premises meet the requirements of the local fire services and planned maintenance of decoration is completed as scheduled. The home should revisit staffing 28/02/08 levels and deployment, especially for the night shift and make suitable staffing arrangement to prevent any neglect or harm to the service users’ with out further delay. The home must ensure that nutritional assessments are carried out and are reflected in their care plans to evidence dietary needs and choices are considered suitably for each individual service users’ and that is reflected in their daily food menu. The home must ensure that a manager is appointed and DS0000015002.V357650.R01.S.doc 4. YA17 13 (5) & schedule 3 28/02/08 5. YA37 8 15/03/08 117A & B Hitchin Road Version 5.2 Page 24 6. YA39 24 application submitted to the commission for registered manager. The home must ensure that internal monitoring is consistently carried out and records updated on time. 28/02/08 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 YA35 YA6 Good Practice Recommendations The home should update the records pertaining to staff training needs, trainings undertaken and planned. Arrangements should be made to ensure that service user plans are made available in a suitable format that the service user can understand. 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 117A & B Hitchin Road DS0000015002.V357650.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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