Inspection on 01/02/08 for 13-15 Constitution Hill

This inspection was carried out on 1st February 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

13-15 Constitution Hill 23/01/09

13-15 Constitution Hill 03/08/06

13-15 Constitution Hill 19/01/06

13-15 Constitution Hill 16/08/05

13-15 Constitution Hill 25/02/05

13-15 Constitution Hill 02/09/04

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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

CARE HOME ADULTS 18-65 13-15 Constitution Hill Norwich Norfolk NR3 4HA Lead Inspector Mrs Judith Last Unannounced Inspection 1st February 2008 3:20 13-15 Constitution Hill DS0000027382.V358914.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 13-15 Constitution Hill DS0000027382.V358914.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. 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 13-15 Constitution Hill Address Norwich Norfolk NR3 4HA 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) 01603 789450 NO FAX # Mr M Talbot Mrs J Talbot Mr M Talbot Care Home 16 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (12) of places 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd August 2006 Brief Description of the Service: Constitution Hill is a Care Home that provides services and single room accommodation to 16 residents, 12 falling into the category of Adults with a Mental Disorder and 4 falling into the category of Learning Disability. It is located close to the city centre and its amenities and within easy walking distance of a number of pubs, shops and takeaways. The home itself is made up of two semi-detached Victorian houses joined together to form one house, resulting in spacious communal accommodation and large gardens. Fees are according to dependency and are specified in individual terms and conditions. 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Our visit was unannounced and we were at the home for nearly four hours. We got information from the owner, two staff members and the records we saw. We briefly looked around the home and listened to what was going on. Four people spoke to us briefly, but did not want to discuss anything with us. We spoke to one person in more detail. We got other information from the Annual Quality Assurance Assessment (AQAA) that Mr Talbot provided to us, from our records and about the things that we know have happened since we last visited. Care services are judged against outcome groups which assess how well a provider delivers outcomes for people using the service. We have rules that tell us how to do this and then tell us how well the service is doing overall. These give extra importance to groups that we consider reflect management and safety. At the moment people are getting an adequate service. What the service does well: The owner/registered manager is regularly at the home providing support and advice. People living there benefit from a relaxed and friendly atmosphere. A day-to-day manager supports the owner/registered manager and has a good understanding of people’s needs. There are good links with other professionals who can help with supporting people. This includes their physical and mental wellbeing and means that people have access to good support networks to help them with their difficulties. There are not many changes in the staff group and agency workers are not needed. This means that people are supported in a consistent manner by staff who have gained an understanding of their needs, (though we think records do not do justice to this – see below). People are able to use local community facilities and staff understand where people’s health might make this difficult or affect their motivation to join in activities. Staff understand and respect people’s right to make decisions about what they do and the support they need, but will provide extra support and advice where this might be needed. 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who are thinking about using the service would have their needs assessed before moving into the home so that staff knew what support they required. EVIDENCE: Efforts are made to obtain details of the support needs of prospective service users from other people who are involved in their care, including other health and social care professionals. We saw this information on file. There were also additional medical reports in some cases. The day-to-day manager of the service says that they try to avoid emergency admissions and admissions on Fridays where they feel they may not have had time to obtain full information about someone’s needs. This is because they recognise it would be difficult to obtain additional advice and back up from the person’s care manager over the weekend, unless that representative is also attached to the crisis team. This means the home tries to make sure that people have access to the support they may need during their early days at the home. 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Given discussions with staff about people’s needs it is probable that records do not do justice to practice. There is room to improve how needs are set out and how risks are to be managed as well as in organising records systematically. Currently records are variable in consistency and quality. EVIDENCE: We had difficulties securing the views of service users on the day as for the most part they declined to talk to us other than to confirm that they were happy with the service and had no complaints. One person’s file did not have any clear description of current needs and risks together with the support needed from staff despite recent reported and recorded incidents. We were told however, that the person’s care manager has been advised and will be updating a risk assessment for the service. In the interim there is no clear guidance for staff to follow. 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 11 In other cases there was evidence of review by the appropriate teams, but nothing between the annual reviews to show the service checked with the service user in between to see if there were changes or progress. Minimum standards say this should happen every 6 months at least. There are blank templates drawn up by the owner for the service to carry out both reviews and updates to risk assessments as well as documenting care needs, aims and goals. These were not in use on current files. The owner agreed that there had been some slippage in maintaining systems to previous standards. We have made requirements about this. Fortunately this is a small staff team with low turnover and staff we spoke to gave consistent accounts of people’s support needs showing that they understood these were different and treated people as individuals. We asked one person how they knew what people’s needs were and they told us about talking to people to discuss their problems and interests indicating people’s views were taken into account. However, one person’s individual records did show short-term goals and the efforts that staff were making to work towards these with the person concerned. This is good practice. Most service users had notes about the care delivered recorded in a “day book”. This means that retrieval of relevant information for review or health care appointments for example, is time consuming and may result in things being overlooked. It also means that visiting professionals are unable to access information promptly about problems presented by or support given to their client without breaching the confidentiality of others. People could not be empowered to access their own daily records routinely should they want to for the same reason. In the event of any coroner’s or police enquiry original documentation would not be accessible, as it would have to be edited/blanked out and photocopied to protect confidentiality of people not involved. We have made a requirement about this. Daily records did show the efforts that staff made to engage people with decisions about their health and activities and show these decisions are respected. They also show discussion about what people want to do. 13-15 Constitution Hill DS0000027382.V358914.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 and 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use services are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. Some people have more complex needs that compromise their opportunities and motivation and staff are aware of this. EVIDENCE: One person who did agree to talk to us told us about their activities and interests, both inside and out of the home. This included having a job and attending sporting events. It was clear from this and from records that people were encouraged to make use of local community facilities and to do this in as independent a way as possible. During our visit people made use of local shops to get what they wanted, including running errands for one another. 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 13 We were told some people like to read, we saw one person reading the newspaper and that a large bookshelf in the living room was well stocked with different books. There is also a games table in the conservatory and one person told us what sort of games they could play including draughts and table football. Records show people’s links with friends and family and also where these are problematic – for example with relationship breakdown. One person told us their family liked to visit and they had extra armchairs in their room so people could come in. We saw that people had keys for their rooms and the day-to-day manager told us that they are encouraged to use these although some declined to lock their rooms. People came and went freely from the home. Staff told us that they encourage people to let them know when they are going out and when they expect to be back for reasons of safety in the event of fire. Records show that people can join in activities in the home and to socialise with one another as well as staff. Smoking used to be allowed in the conservatory, but now people go outside. This is set out in renewed terms and conditions and the day-to-day manager told us that people were aware of this and cooperated with the policy. Some people had reduced their smoking as a result. People told us the food was good and one person told us that they got together to plan menus. Staff told us that one person has all their food pureed and the care plan file confirmed this and the person’s reasoning and preference. One person told us they were looking forward to the evening meal, which was one they had suggested be included in the menu. Records reflect flexibility in how someone is supported with difficulties around food or drink. They also show that staff recognised and understood complications and worked with the person, family and health care professionals. Records showed that ultimately people’s decisions were respected as well as showing whether there was improvement. The laundry has a machine that people can use to try and encourage people to gain some more independence. The AQAA recognises that the service plans to improve involvement of people with laundry, personal cleanliness and routine housework (keeping their own rooms tidy and clean). This would help people to develop, maintain or improve their independent living skills. 13-15 Constitution Hill DS0000027382.V358914.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 and 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health and personal care needs are met and their medication is managed safely. As with other outcome groups, there could be an improvement in setting out needs and goals in this area. EVIDENCE: Despite some shortfalls in care plans setting out the support people need – including with their personal and health care, daily records show that people are encouraged to be as independent as possible in their personal care. They also show that people are able to request assistance if they feel unwell and that this is provided when asked for. There is good evidence of consultation with relevant professionals, including social workers, consultants and the community mental health team. The dayto-day manager was going to make arrangements to register someone who recently arrived with the local doctors. 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 15 Complications arising from problems with eating are recognised and we saw from records that decisions are respected. Records show consultation with health care professionals when necessary and the efforts that staff make to persuade and inform people about any recommended course of treatment or action. They showed where this was accepted and where refused. We asked a staff member to explain the medication system to us. The person gave a clear account of the procedure from start to finish, including the need to implement good hygiene measures by washing hands and making sure clean pots were used. The pharmacist supplies medicines in compliance aids and the person showed us what they would check when they were giving out medicines. They also told us about a medication in occasional use and that they would not routinely offer this but that the person would ask if they felt they needed it. The person outlined the checks that are made and when records of administration are completed. Records themselves were not fully checked but a sample selected showed no omissions. We know from previous visits that people who are able to, can take responsibility for administering their own medicines, subject to risk assessment. 13-15 Constitution Hill DS0000027382.V358914.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 and 23 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. . Staff try to respond promptly to people’s concerns. However, there have been instances since our last visit when allegations have not been promptly notified or referred. This means that we cannot be confident people’s concerns and complaints are always acted upon quickly. EVIDENCE: There is policy guidance about complaints, protection and whistleblowing and this has all been reviewed in March 2007 based on the AQAA. Staff confirm information in the annual quality assurance assessment (AQAA) that they have had training and understand what to do if someone raises concerns about possible abuse. Daily notes show the efforts that are made to clarify any issues raised. A staff member told us about listening to people and trying to sort out what was worrying them before things got too much of a problem. There was an oversight in notifying the Commission last year of alleged theft of cigarettes from someone living at the home and the police were not contacted promptly. The person who did contact us was concerned that the police had not been informed and that the owner had not acted proactively. There was also an allegation of assault. This was referred to the adult protection team, but the owner again failed in his legal duty to notify the Commission. The police informed us that there was no evidence, but also raised a concern that a temporary arrangement to support people (a policy of 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 17 no “lone” working) had not been adhered to. Mr Talbot was written to about these issues and said that failure to notify had been an oversight. Four people told us they had no complaints about their care and did not want to talk to us. Mr Talbot has written in the AQAA that he is aware of how documentation could be improved as an additional protection, for example when handling monies on behalf of service users. He also says the complaints record could be improved. These would be welcome improvements in showing how the outcomes are better achieved and that there is a robust system for pursuing people’s concerns and allegations. 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 18 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a comfortable, clean and generally safe environment. Regular damage to one carpet needs monitoring and action to avoid a hazard developing. EVIDENCE: There has been no change to the structure, and space available. We did not inspect the environment closely. This is because previous inspectors and inspections have considered it met on three separate occasions since 2005. There has been some redecoration to improve the environment for people. The home was comfortably warm. We saw one room at the invitation of the occupant. This was personalised and items in it reflect the person’s interests. The carpet was badly damaged beneath a chair and needs covering, repair or replacement so that is not a trip hazard. The manager, owner and service user 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 19 are aware that this is a recurring problem. We have made a requirement about this. Fire detection systems are tested regularly and people living at the home participate in regular drills as well as fire training. The kitchen was clean with detailed cleaning schedules for daily, weekly and monthly action. This is good practice. The laundry is small but the day-to-day manager reports that it is able to cope with the amount of laundry generated by service users. There were no concerns about hygiene or unpleasant smells noted in the areas seen. 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 20 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 and 36 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by staff who are sensitive to their needs and have training in relevant areas although a more robust approach to showing competence through induction could be shown. Staff are poorly supervised in relation to national minimum standards EVIDENCE: The annual quality assurance assessment (AQAA) the manager sent to us before we visited tells us that there are five staff working at the home, of whom 3 are working towards National Vocational qualifications (NVQ). This means the service does not yet meet the minimum standard for 50 of staff being qualified. The day-to-day manager and owner are very experienced in working in the home and with people’s needs. Staff confirm information in the AQAA that they have had the training in protecting vulnerable adults required at the last inspection. 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 21 We looked at recruitment files for two people recruited since our last visit, which showed that enhanced criminal records bureau disclosures, employment histories and references had been obtained. Staff told us training was good and some certificates are on the wall. The plastic wallets containing records are not organised into any consistent format so it is difficult to see how probation and induction periods are managed and whether people living at the home are involved in the review process. Copies of training certificates are not held in these files to provide a consistent and clear record. We have made a requirement about this. Induction folders contained a lot of relevant reference information for staff, but not consistent evidence that their understanding and competence had been assessed or checked in the areas specified by Skills for Care Common Induction Standards. However, we concluded from discussion that staff had a good understanding of their roles and the needs of people they support, including that these can change quickly and significantly. We heard interactions between staff and service users, which showed respect to people. Supervision was the subject of a requirement at two previous inspections, but not the last when the situation had improved. The owner records in the annual quality assurance assessment that this is something they could do better. This and the lack of appropriate records tell us the improvement has not been sustained. The owner cannot properly show for example, appraisal of staff performance on a regular basis and an assessment of development and training needs for each individual. We have made a requirement about this. 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 22 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home is under the control of a competent and very experienced owner/manager who helps to promote people’s safety. However, there is a need now to be more proactive in addressing acknowledged slippage and identifying further improvements the service can make in the interests of those who use it. EVIDENCE: Mr Talbot has been working in the business for over 20 years. Inspection in 2005 showed that the management qualifications were met. We did not check this again. He has reviewed the policies and procedures in use. The AQAA shows that these were reviewed in March 2007. 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 23 From observation there was a good rapport between staff members and the owner/manager. Staff say they are able to go to him or to the day-to-day manager with queries. The annual quality assurance assessment (AQAA) completed by the owner, identifies improvements that have been made in the last 12 months. However, evidence cited to show what is done well does not always list a range of evidence that is currently in the home to support claims. (For example under environment and under this section there is no reference in evidence to maintenance of contracts, test reports, etc.) If completed rigorously we would also expect the AQAA to show what stakeholders’ views were, under the relevant sections of what is done well and what could be improved. We last had analysis of survey findings in 2006 following requirements at two successive inspections. We have not been sent any update of these results. We have made a requirement about this. We were shown records associated with health and safety. These show appropriate safety and maintenance checks. There were records of fire testing, drills and training, and of checks on emergency lighting and fire extinguishers showing these are tested regularly. Staff confirm training in first aid. This means we think there are measures in place to help promote the safety and welfare of people living and working at the home. Accidents are recorded in a small notebook rather than in a record that provides for confidentiality of reporting. We have made a recommendation about this. 13-15 Constitution Hill DS0000027382.V358914.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 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 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 2 33 x 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 2 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x x 3 x 13-15 Constitution Hill DS0000027382.V358914.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 15.1 Requirement There must be up to date support plans for people with their current goals and aims so people are supported properly. If these are not in place and easily accessible people may not be supported properly. Support plans must be reviewed with people at least every six months – more often if needs change. If they are not, then people may have their needs overlooked and may not have a regular say in how they want to be supported. Records of care delivered must be kept in such a way that the privacy and confidentiality of the individuals to whom they relate is protected. The torn carpet must be repaired or replaced, or alternative arrangements made. This is so that people are not placed at avoidable risk of accident. Timescale for action 31/03/08 2. YA6 15.2 30/04/08 3. YA10 12.4 31/03/08 4. YA24 13.4 31/03/08 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 26 5. YA35 19, Sch 2 no.5 Copies of certificates for the training people have completed, must be held on their files. This is to show that staff have sufficient relevant training at appropriate intervals, to help support people properly. Staff must have adequate supervision with the frequency and nature set out in standards. This is so the management team can make sure staff understand people’s needs and are properly supported and developed themselves. This was subject of a requirement at two previous inspections, with improvement noted at the last not being sustained. 31/03/08 6. YA36 18.2.a 30/04/08 7. YA39 24 There must be a system for monitoring and reviewing the quality of the service at appropriate intervals. The system must provide for consultation with people living at the home and other interested parties. The report compiled must be supplied to the Commission. This is so the manager can show that there is a proactive approach to developing the quality of the service, which takes into account the views of those with an interest in it. This standard was a subject of requirement at two previous inspections, with improvement noted at the last not being sustained. 30/06/08 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 27 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 YA42 Good Practice Recommendations The owner should consult with environmental health about existing systems of recording accidents that happen in the home. This is to make sure that they comply with their responsibilities under other legislation and with good record keeping practices. 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 13-15 Constitution Hill DS0000027382.V358914.R01.S.doc Version 5.2 Page 29 - 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!