Inspection on 15/08/07 for 12 Alfred Street

This inspection was carried out on 15th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

12 Alfred Street 22/08/06

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 12 Alfred Street Gloucester Gloucestershire GL1 4DF Lead Inspector Mr Paul Chapman Key Unannounced Inspection 15th August 2007 09:00 12 Alfred Street DS0000067435.V345938.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 12 Alfred Street DS0000067435.V345938.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. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 12 Alfred Street Address Gloucester Gloucestershire GL1 4DF 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) 01452 550452 www.holmleigh-care.co.uk Holmleigh Care Homes Ltd Lindsey Marie Riley Care Home 2 Category(ies) of Learning disability (2) registration, with number of places 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2006 Brief Description of the Service: The property is a two bedroom terraced house in Gloucester. To the rear of the property is a good-sized garden that is well maintained. The accommodation comprises of a separate lounge and dining room with the kitchen to the rear of the property. On the first floor are two good-sized bedrooms. Currently the service is provided for two men with mild learning and physical disabilities. The home is staffed 24 hours a day, 7 days a week with a minimum of one staff member being on duty at all times. Fees for the home range from £800.00 to £1200.00 per week. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This inspection took place on 15th August 2007. On arrival at the home one of the senior care workers were on duty and spent some time with the inspector discussing what it was like to work at the home. The registered manager arrived soon after and was in attendance throughout the rest of the site visit. The CSCI supplied the manager with the Annual Quality Assurance Assessment (AQAA) prior to the inspection. This was completed and used as part of this site visit. Both people living in the home, and one staff member completed surveys. Time was spent observing the care of both people and their interactions with staff. One person living in the home spoke to the inspector whilst the other person declined. One person showed the inspector their bedroom. The care of both people was looked at in depth that included looking at their financial, medication and personal records. One member of staff was spoken with about the care they provide. Other records examined included staff files, health and safety information and quality assurance records. What the service does well: What has improved since the last inspection? Both people have residency agreements. People living in the home have detailed care plans that identify their needs and the steps that need to be taken by staff to meet them. All of the care plans examined were reviewed regularly. The manager has completed risk assessments for each of the people living in the home that minimises potential risks. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 6 People are empowered to choose goals they wish to achieve and records provide evidence that people are supported to achieve them. Both people have been issued with a copy of the home’s complaints procedure. The manager is developing quality assurance systems. The standard of the accommodation has improved with the new kitchen and bathroom being fitted. The manager has implemented health and safety audits of the service. 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. The summary of this inspection report can be made available in other formats on request. 12 Alfred Street DS0000067435.V345938.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 12 Alfred Street DS0000067435.V345938.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): 2, 5 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has an admission policy that minimises the potential risk of people being admitted to the home whose needs cannot be met. EVIDENCE: A requirement of the previous inspection report was that each person living in the home should have an individual contract of care with the service provider. Examination of both people’s files showed that these contracts are now in place. No new people have been admitted to the home since the previous inspection was completed. The home has a referrals and admission policy. 12 Alfred Street DS0000067435.V345938.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, 8, 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home have care plans that identify their needs and the steps that need to be taken by staff to meet them. Decisions are taken by the people living in the home. Potential risks to people are minimised through comprehensive assessment. EVIDENCE: A requirement of the previous inspection report was that care plans must be developed to meet people’s needs. The care files for both people living in the home were examined in detail. Both files have been completely re-developed since the previous inspection and provide the reader with comprehensive information about each person. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 10 Both people now have care plans that cover most aspects of their lives. Examples seen for both people included: • Communication • Maintaining a safe environment • Mobility • Eating and drinking • Emotional needs • Daily living skills • Social skills • Cultural needs • Health • Medication • Personal hygiene • Accommodation requirements • Financial management • Managing behaviour • Activities All of the care plans examined had been reviewed. The manager must ensure that care plans and risk assessments are in place that address people’s sexual behaviour. This becomes a requirement of this inspection report. A number of the documents examined in people’s files were not dated and the manager must address this. Daily notes provided evidence that staff had supported both people with their care plans since January 2007, but the manager must be mindful of this recording. Daily records should record if staff have offered someone something and they have refused. This becomes a good practice recommendation of this inspection report. One person living in the home spent time talking to the inspector giving their thoughts about the home. They confirmed their role in developing their care plans and Person Centred plan (PCP), and explained what they felt it was like living in the home day to day. They stated that they make decisions about what they like to do. The other person was asked whether they wished to complete a PCP and they refused. Each person has a target book. These books identify goals that they wish to achieve. Evidence was available showing the goals that had been achieved. Speaking with one person they explained their goals and agreed that staff had supported them to achieve them. An example of a goal that has been achieved includes one person organising their birthday party. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 11 A requirement of the previous inspection was to ensure that risk assessments were completed for both people that enabled them to take part in activities while potential risks are minimised. Both files now contain comprehensive risk assessments completed by the staff. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Both people lead active lifestyles and are supported by staff appropriately where it is required. EVIDENCE: Each Sunday staff complete activity sheets with each person that plans activities for the coming week. Examination of a sample of these documents showed both people completed a range of activities. Speaking to one person they confirmed that these activities take place. As mentioned earlier in this report the manager must ensure that the daily notes accurately reflect what activities have taken place. If they have not taken place the reason should be recorded. When speaking to one person they explained some of the activities they completed regularly and their plans for the coming months. They explained 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 13 that they have been attending College 4 days a week where they have been completing a course in numeracy, literacy and completing job application forms. In addition to this they are involved in a gardening project run by the organisation who are currently re-developing a garden in another home. As well as being involved in this gardening project the person has been developing the garden at Alfred Street. They took the inspector to see what they had planted and showed them a number of photos of them tending the garden. As well as attending the college they also attend the organisation’s day service where they are doing training in money management. Other activities they regularly complete include playing basketball, horse riding, going into Gloucester and visiting pubs. They explained that in the coming year they are going to do a cooking course which will include completing their food hygiene certificate. The other person living in the home did not wish to speak to the inspector during the inspection. Examination of their records showed that they lead an active lifestyle. Both people have regular contact with their relatives. One person’s sister had visited them at the home on the day before this site visit. The other person had invited their relatives to their birthday party. Both people are asked to be involved in completing tasks around the home including their washing, ironing, cooking and cleaning. The home uses the safer food, better business package to minimise potential risks. The person who spoke to the inspector said that they enjoy helping prepare meals with the staff, and “the food is nice and there is plenty of it”. Both people living in the home are involved in shopping for the ingredients for their meals. The meals are chosen by the people living in the home and it is a 3-week rolling rota, the person speaking to the inspector said “we can have something else if we don’t want what is on the menu”. The people living in the home review the menu every 2 months. As well as cooking meals people also have take-aways regularly. A good practice recommendation is to review the use of the 3-week rolling rota and move to a system that allows people to make choices more frequently. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager has recognised the shortfall of their staff team in working with other professionals and steps have been taken to address this. Medication administration has improved and people are no longer being put at unnecessary risk. EVIDENCE: Neither person in the home needs physical support with their personal care and support consists of prompting/reminding. Records seen in peoples personal files showed that the home use other professionals to meet people’s needs. A requirement of the previous inspection report was for the manager to ensure that people’s physical needs were met. Specifically it related to one person requiring specialist speech and language therapy input. Before this site visit was completed the inspector was contacted by the speech and language therapist who was concerned by the staff teams approach whilst working with 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 15 them recently. The incident focused on one person not being supported by the staff to use a communication tool supplied by the CLDT (Community Learning Disability Team). The inspector put these concerns to the manager. They admitted they had become aware of this situation and agreed that it had been unacceptable. The manager explained what steps they had taken to address this. In addition to speaking with the manager the inspector spoke to another staff member who key works the person in question. They explained that they felt the manager had addressed this appropriately and plan to work constructively with the CLDT in the future. Staff have completed OK Healthcheck booklets (a method for assessing and planning healthcare needs for people with learning disabilities) with both people. Staff have just started to complete Health Action plans for each person. Appointments with other professionals are recorded by the staff. A shortfall identified as part of this site visit was that one person was admitted to hospital earlier this year. Regulation 37 of the Care Homes Regulations (2001) states that the CSCI should be informed of all hospital admissions. This was brought to the attention of the manager. This becomes a requirement of this inspection report. Medication administration was examined. The previous inspection report made 3 requirements relating to the home’s medication. The requirements were: • • • Medication must be stock checked on entering the premises. This is now being done. Any medication to be returned to the pharmacist must be recorded. This is now being done. All topical creams should be labelled with the date they are opened. Topical creams seen on this occasion were labelled appropriately, but a bottle of cough medicine was not labelled with the date it was opened. This becomes a requirement of this inspection report. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Potential risks to people are minimised through a robust complaints procedure and being supported by staff that have completed training in safeguarding adults. EVIDENCE: The home has a complaints procedure and a copy was on the notice board. The manager stated they she has not received any complaints since the previous inspection was completed. The CSCI have not received any complaints. A requirement of the previous inspection report was for each person living in the home to be issued with a copy of the home’s complaints procedure. The person who spoke to the inspector said that they had a copy of the procedure. They explained that they have used the procedure in the past and felt it had worked well and they were satisfied with the outcome. Staff complete training in safeguarding vulnerable adults. The training programme for this year showed that all members of staff would complete this training. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 17 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, 25, 26, 27, 28, 29, 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides people with a comfortable, homely and clean environment that meets their current needs. EVIDENCE: As part of the site visit all of the communal areas were seen and one person showed the inspector their bedroom. Since the previous site visit was completed the kitchen and bathroom has been replaced. Both areas were being finished at the time of this site visit. The manager explained that all of the communal areas will be decorated and the carpets downstairs will be replaced. One of the bedrooms is due to be decorated in the near future. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 18 The inspector saw one of the bedrooms, it was personalised with their possessions including a TV, DVD player, pictures and models that the person makes. The person to whom the bedroom belongs said that the window leaks on the right hand side, this must be investigated and becomes a requirement of this inspection report. In addition to this plaster had fallen off the ceiling, this must also be addressed. To the rear of the property there is a crack above the bathroom window, the manager said that this had been reported but not yet addressed. In addition to this the gutting to the rear of the property needs repairing as it is overflowing at the moment. One person living in the home has a fire alarm light in the their bedroom which flashes when the alarm goes off. The manager says that this needs to be moved as it is difficult for him to see in it present position. This becomes a requirement of this inspection report. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff receive training that minimises the potential risk of peoples needs not being met. Staff recruitment procedures need to be followed consistently to ensure that people are not put at unnecessary risks. EVIDENCE: Members of staff have different responsibilities within the home. The inspector spoke to one staff member who explained that they have the responsibility for overseeing food hygiene/safety in the home. They explained that their background is in catering and from the conversation take their responsibility seriously. Other staff have different responsibilities including completing health and safety audits. Speaking with one of the people living in the home they said that they would like to be involved in the interviews for future staff. The manager was present at this point and agreed that this would happen in the future. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 20 Two staff have started at the home since the previous site visit was completed. Both of the staff files were examined. One had no shortfalls, while the other had no records of previous employment. It becomes a requirement of this inspection report that this is addressed. Staff training records were examined. This provided evidence that staff had completed Makaton training and the majority of the staff team had completed mandatory training in subjects including medication, fire safety, food hygiene, first aid, infection control, equality and diversity, safeguarding adults, learning disabilities and induction for new staff. The manager has developed a training file that identifies courses planned for the future. Courses included: Food hygiene, Positive behaviour management, first aid, manual handling, COSHH, safeguarding adults, mental capacity act, learning disabilities, equality and diversity and autism. The home employs 5 permanent staff. The manager has completed an NVQ level 4, while another staff member has completed a level 2 in care. The manager stated that another member of staff has just started an NVQ level 2 in care. The staffing rota was examined and showed that the home was staffed 24 hours a day, 7 days a week. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 21 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, 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager is appropriately qualified and experienced to run the home. Their leadership and review of the service has improved the quality of the outcomes for people living in the home. The quality of the service provided is monitored by the manager and her staff which ensures people are not put at unnecessary risks and enables outcomes to be improved. Health and safety is taken seriously by the manager and staff and minimises the potential risks to people. EVIDENCE: At the time of this site visit being completed the manager had been in post for almost a year. The manager is registered with the CSCI after successfully completing the registration process. The manager has completed the Registered Manager’s Award. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 22 The CSCI received a completed Annual Quality Assurance Assessment (AQAA) before the site visit was completed and this was seen to be an accurate reflection of the service being provided. Since the previous inspection was completed the manager has overhauled the care administration in the home. This system now provides a good level of evidence to support that people’s needs are being met. Some shortfalls have been identified and discussed with the manager and they gave their commitment to address them over the coming months. Both of the people living in the home have been asked to complete a questionnaire about the service they receive living in the home. It is planned that they will be asked to complete these questionnaires annually. The manager must ensure that they provide evidence that they have analysed the questionnaires and addressed any shortfalls. They should also highlight any areas of good practice. Each month a member of the staff team has the responsibility for completing a health and safety audit. Records showed that these had been completed regularly and covered areas including: - building and estate, equipment and facilities, kitchen and food hygiene and fire safety. In addition to this monthly audit other audits being completed included medication practice and vehicle safety. The director of the organisation completes regulation 26 visits regularly. The manager explained that they intend to implement an audit to review the skills of the workers in the home using staff supervision session’s feedback to staff. The inspector suggested that in addition to the current audits being completed the manager could look at the quality of areas including food, care plan reviews and activities. This becomes a good practice recommendation of this inspection report. As mentioned previously health and safety audits are completed monthly and examination of the completed audits showed that where shortfalls are identified they are addressed appropriately. The manager has completed a fire risk assessment for the home in March this year. Examination of the document showed that it was detailed. Other records relating to fire safety showed that an evacuation had been completed, staff complete training, smoke sensors are tested regularly and the extinguishers were serviced by an engineer in November 2006. Portable appliance testing (PAT) was completed this month. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 23 Fridge and freezer temperatures are recorded twice daily and a food probe is used to monitor the temperature of cooked meals. The home uses the “safer food, better business” workbook issued by Food Standards Agency. 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 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 2 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 3 X 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Care plans must be developed to meet the needs of the people living in the home as identified in the body of the report. When ever a person living in the home is admitted to hospital the manager must inform the CSCI. Cough mixtures must be labelled with the date they are opened. The crack in the wall above the bathroom window must be investigated and repaired. The guttering around the home must be cleaned out so it works effectively. 5. YA26 23(2)(b, c, d), (4)(c) ii, The leak to the right hand side of 16/11/07 one person’s bedroom window must be investigated and repaired as required. The plaster is falling off the ceiling in one of the bedrooms and this must be repaired. In the other bedroom the light 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 26 Timescale for action 12/10/07 2. YA19 37 14/09/07 3. 4. YA20 YA24 13(2) 23 (2) (b) 14/09/07 16/11/07 that flashes when the fire alarm sounds must be re-sited to ensure that it is easily visible by the person. 6. YA34 7, 9, 19 Schedule 2 The employment records that were missing from the file examined must be put in place. The organisation’s recruitment policy must be followed consistently too ensure that people are not put at unnecessary risks. 26/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA7 Good Practice Recommendations Daily notes written by the staff team should provide evidence of activities completed, or the reason why they were not. The home’s menus should be reviewed with the aim of the menu being chosen more frequently. The manager should ensure that all documents are dated. The questionnaires completed by the people living in the home should be analysed by the manager and shortfalls/concerns addressed. The manager should continue to develop the quality assurance system as recommended in the body of the report. 2. 3. 4. YA17 YA37 YA39 5. YA39 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 12 Alfred Street DS0000067435.V345938.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!