Inspection on 05/09/06 for 2 Dunstans Drive

This inspection was carried out on 5th September 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

2 Dunstans Drive 30/12/05

2 Dunstans Drive 27/06/05

2 Dunstans Drive 25/10/04

2 Dunstans Drive 06/05/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 2 Dunstans Drive Winnersh Wokingham Berks RG41 5EB Lead Inspector Mrs Rhian Williams-Flew Unannounced Inspection 5th September 2006 10:00 2 Dunstans Drive DS0000051745.V307446.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 2 Dunstans Drive DS0000051745.V307446.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. 2 Dunstans Drive DS0000051745.V307446.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2 Dunstans Drive Address Winnersh Wokingham Berks RG41 5EB 0118 979 5362 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) caroline.bilsby@new-support.org.uk www.new-support.org.uk New Support Options Limited Mrs Caroline Lisa Bilsby Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 2 Dunstans Drive DS0000051745.V307446.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th December 2005 Brief Description of the Service: 2 Dunstans Drive provides accommodation and personal care for four adults who have learning and associated physical disabilities. The accommodation is a purpose built bungalow and is sited on a residential estate. Toynbee Housing Association Group owns the building and the care is provided by New Support Options. The home is situated approximately ten minutes from Wokingham and Reading town centres; all community facilities are easily accessible with shops within walking distance. The home has its own vehicle and there is good access to public transport. The Registered Manager confirmed in August 2006 that the current fees charged for each service users care is £1327.25. Additional charges are made to the service users or their representatives for chiropody services; hairdressing, toiletries, clothing; day services activities and various community activities. The home has a statement of purpose that describes the service provided. Access to any reports published by the Commission for Social Care Inspection about the service provided are available in the home. 2 Dunstans Drive DS0000051745.V307446.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence used to inform this report includes a pre-inspection questionnaire completed by the Registered Manager of the home; our inspection records held at the local office of CSCI; an unannounced site visit on 5 September 2006. The site visit took place between 10.00am and 6.30pm and was conducted by one Inspector. During the unannounced site visit conversations were held with the members of staff on duty; observations were made of the delivery of care; a tour of the home was made; all case files were case tracked and some records concerning the management of the home were reviewed. The service users had been sent CSCI questionnaires about the care they receive prior to the site visit. Members of staff had completed the questionnaires on their behalf. The Registered Manager was not present for the site visit although the Deputy Manager was. It was not possible to seek the views of the service users’ as they are unable to converse in verbal conversation. Observations of their interactions with members of staff throughout the visit clearly demonstrated that they are able to make their wishes known through non-verbal communication. What the service does well: What has improved since the last inspection? The general decoration and furnishings of the home and the garden area of the home have improved. Further work is planned for the garden area. The established staffing team has improved and further recruitment is in progress. Opportunities for staff to receive training has also improved. 2 Dunstans Drive DS0000051745.V307446.R01.S.doc Version 5.2 Page 6 Two previous requirements regarding the training of staff in the protection of vulnerable adults and the implementation of a written record of complaints have been met. 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. 2 Dunstans Drive DS0000051745.V307446.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 2 Dunstans Drive DS0000051745.V307446.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. There are systems in place to ensure that all new service users would be assessed to ensure their care needs could be met prior to being offered placement at the service. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The most recently admitted service user arrived in 2003. Therefore, there have been no recently admitted service users since the previous inspection in December 2005. The Deputy Manager was able to assure that any new service users would only be admitted on the basis of a full assessment either completed by a Care Manager and/or the Registered Manager for the home. Inclusion of family carers and service users views would be involved in this process. 2 Dunstans Drive DS0000051745.V307446.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is poor. The care plans and risk assessments for service users could not be evidenced as current and up-to-date. In some cases the information contained in the care records provided conflicting advice with regard to the support service users required. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Conversations with the service users about their care plan needs was not possible because of their limited communication skills. However, discussions were held with three members of staff including the Deputy Manager as to how members of staff understand whether a service user is content with the care they receive. From these conversations it became evident that the members of staff on duty had a good understanding of the likes and dislikes of each service user and how they communicated these emotions. The members of staff were able to detail specific habits and preferences for each of the service users and to advise on their daily activities and social contacts. 2 Dunstans Drive DS0000051745.V307446.R01.S.doc Version 5.2 Page 10 Verification of these specific care needs and preferences should have been reflected in the service users plans and risk assessments. All of the service user care records were case tracked during the site visit. The evidence in these care records did not wholly reflect the information provided by the staff team or the observed practice during the site visit. The information in some care records presented conflicting information. For example, it was suggested in one part of a service users records that they should be given rectal diazepam at a certain point during epileptic seizures yet they had not been prescribed this medicine for sometime and it was no longer current advice. For all service users they had detailed and specific guidelines about the 24-hour care. This was detailed and thorough but undated and not signed. Adjacent to these guidelines were personal plans that detailed similar but not the same information to the 24-hour care guidelines. These personal plans were all dated 2004. It was therefore not possible to elicit which was the most current information that staff should be seeking guidance from. In addition, it could not be evidenced that any of the plans had been reviewed regularly (ie. at least every six months). For one service user a pathway to care was found (dated June 2005) but such documents were not found for the other service users. It could not be evidenced that any of the service users had an independent advocate although some of them do still have support from family members who are consulted when decisions and choices have to be made to meet the service users needs. During discussions with the Deputy Manager she identified that for one service user their family had moved house in the past year yet the service users case records did not record their current address. As with the care plan records the individual service user risk assessments did not appear to be up-to-date as they had not been reviewed regularly and if they had been reviewed no date was identified as to when this had occurred. There were exceptional incidents of risk assessments being last dated in 1999. The development of an up-to-date and thorough care plan and risk assessments for each service user is an imperative to ensure that care delivery is consistent and accurately delivered. The evidence of the site visit did not demonstrate this. In subsequent discussions with the Registered Manager she acknowledged and accepted that this was an area of improvement that needed to be complied with promptly. 2 Dunstans Drive DS0000051745.V307446.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. All the service users have access to activities that they enjoy and can participate in. Their activities are varied and are provided in various community resources within the local area. The provision of nutritional and varied menus is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: All service users take part in valued and fulfilling activities. Evidence with regard to this was seen during the site visit as a timetable of activities for each service user is kept. Members of staff spoken with had a good understanding of each service users daily activities and their participation and enjoyment in this. The activities are varied and reflected each service users particular enjoyment. The home is situated within a residential development and is very much part of its local community. Access to local facilities is good. All the service users 2 Dunstans Drive DS0000051745.V307446.R01.S.doc Version 5.2 Page 12 have access to an adapted vehicle. Not all staff are qualified or confident to drive this vehicle therefore this sometimes limits the service users access to the vehicle. The Deputy Manager assured that when this occurs the use of taxis is authorised. It was evidenced during observations on the site visit that staff are respectful of the service users right to privacy and dignity. Members of staff were noted to be inclusive of the service users in activities around the home. Family links and friendships are positively encouraged with some of the service users visiting their family homes with the assistance of members of staff. Included in the pre-inspection questionnaire were copies of the recent menu selections for the home. They were noted to be nutritious and varied. During the site visit evidence was seen of the evening meal being prepared from fresh ingredients, including some vegetables grown in the garden of the home. 2 Dunstans Drive DS0000051745.V307446.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. The home ensures that the health-care needs and personal support needs of the service users are met. This judgement has been made using available evidence including a visit to the service. EVIDENCE: From the evidence of the 24-hour guidance notes within each service users care plan there were detailed instructions on how their personal support should be provided and their preferences with regard to this. As previously stated the difficulty was establishing whether this guidance was the most current as it was undated. From conversations with members of staff and observations of the service users during the site visit it was evident that service users do receive flexible personal support. One area of the service users case records that was consistently up-to-date were the records concerning their health-care needs. Some of the service users health-care needs are changing and this was reflected. There was good evidence that service users are receiving specialist support from diabetic clinics, epilepsy services, psychiatric reassessment etc. Some of the service users have care needs that require them to have specialist wheelchair facilities, hoists and height adjustable beds. From conversations with the Deputy 2 Dunstans Drive DS0000051745.V307446.R01.S.doc Version 5.2 Page 14 Manager it was indicated that reassessment by a qualified physiotherapist and/or occupational therapist might be required to ensure the right level of equipment and support is available for these service users. The storage, receipt and administration of medication were reviewed during the site visit and noted to comply with the homes own policies and procedures. The home does administer controlled drugs. It is recommended that the home acquire a copy of the regulations and guidance issued by the Royal Pharmaceutical Society of Great Britain to ensure they are following this practice with regard to the storage and administration of controlled drugs. There was evidence available to identify that in recent times two members of staff had been suspended from administering medications due to errors. It was noted that the Registered Manager acted appropriately in suspending them from the task and ensured they received retraining and reassessment before being permitted to undertake the administration of medications again. 2 Dunstans Drive DS0000051745.V307446.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. The Registered Manager has ensured that there is a robust complaints procedure in place. She has also ensured that her members of staff receive training in the protection of vulnerable adults thus safeguarding the service users who live in this home. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A previous requirement to record complaints has been met. The record of complaints was reviewed to evidence this. There had been two complaints since the previous inspection. There was good evidence that the Registered Manager was addressing any complaints she had received promptly. During the site visit it was not possible to clearly evidence if all members of staff had received training in the protection of vulnerable adults. Subsequent to the inspection the Registered Manager has provided such information and sufficient evidence has been presented to demonstrate that a previous requirement that members of staff receive training in the protection of vulnerable adults has been achieved. It is only the most recently appointed members of staff that still require this training and evidence has been provided to demonstrate that the courses have been applied for. In discussions with some members of staff it was evident that they had good understanding of the need to protect service users from the risk of abuse and whom they should report any issues of concern to. 2 Dunstans Drive DS0000051745.V307446.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. The facilities provided in this home are spacious and accessible to the service users, some of whom use wheelchairs. The home is generally well decorated, furnished, clean and hygienic. An exception is the provision of facilities within the kitchen area and the need for refurbishment in the shower room. This judgement has been made using available evidence including a visit to the service. EVIDENCE: All service users have access to ground floor accommodation that is large and spacious. 3 of the 4 service users use wheelchairs. All areas of the home are accessible to the service users. Since the commissioning of the accommodation (some years ago) the facilities in the kitchen area do not meet the needs of the service users and members of staff in the home. It is understood that the landlord of the property (Toynbee Housing Association) and the provider of care (New Support Options) have been unable to agree until recent times as to whose responsibility it is to address the deficits in the kitchen area. The Deputy Manager was able to confirm that they had received recent notification that both organisations had 2 Dunstans Drive DS0000051745.V307446.R01.S.doc Version 5.2 Page 17 decided upon a way forward but no timescale had been given as to when this work would commence. Considering the length of time taken to reach this point it would seem imperative that actions are taken as during the site visit it was evident that the health and safety needs of staff are being compromised because of the height of the work surfaces and the poor operation of some of the equipment in the kitchen. It is acknowledged that the Registered Manager and her staff team have been tireless in their efforts to resolve this problem but defined commitment from the two organisations concerned is required to advance the situation. The Deputy Manager also advised that a similar scenario has developed with regard to the replacement of the shower door as neither organisation have accepted responsibility for its replacement. Both these issues do have impact on the service users who live in this home and for this reason the Commission for Social Care Inspection will be placing a requirement on the Responsible Individual for New Support Options to resolve these issues promptly. The general decorations of the home (with the exception of the kitchen and shower room) are in good order. Furnishings are being replaced and the home is comfortable and homely. The Deputy Manager advised that the room furnishings of some of the service users are being replaced. The garden has been partially transformed and the Deputy Manager confirmed that there are plans to continue the planting. The Registered manager should update the risk assessment for the garden area, as there are some uneven paving slabs. These might require relaying. The premises are clean and hygienic and free from offensive odours. As the laundry facilities are not adjacent to the service users rooms it is recommended that the Registered Manager consider whether the use of red alginate bags to transport soiled laundry from the bedroom areas to the laundry would be advisable. 2 Dunstans Drive DS0000051745.V307446.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is adequate. The recruitment procedures in this home are robust. The Registered Manager ensures that her members of staff have access to training. The staffing in the home has improved since the previous inspection. However, the Registered Manager must facilitate the supervision of the staff. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Since the previous inspection several members of new staff have started at the home and during the week of the site visit additional interviews were taking place for the appointment of further staff. The Deputy Manager confirmed that introducing such numbers of new staff requires adjustment for not only existing staff members would also the service users. The Registered Manager has provided sufficient evidence to demonstrate that the most recently appointed members of staff have either attended their mandatory training or are booked to attend. In addition, 2 of these recently appointed members of staff have applied to commence their NVQ training. In discussions with members of staff they showed commitment to undertaking mandatory training and vocational training qualifications. 2 Dunstans Drive DS0000051745.V307446.R01.S.doc Version 5.2 Page 19 A random sample of the records of the most recently recruited members of staff were reviewed and were found to comply with the regulations of the Care Standards Act. However, it is recommended that the Registered Manager ensures that the photographs kept of members of staff are clear and it is possible to identify the person from the photograph. The supervision records of a random sample of staff were reviewed and found to be absent. It was not possible to evidence that the Registered Manager has conducted regular supervision (up to 6 times a year) for each member of staff. In conversations with members of staff they were unable to recall when their last supervision session had been or whether they had received notes of the meeting. Subsequent to the site visit the Registered Manager confirmed that she had not completed sufficient supervision sessions with her members of staff nor had they received notes of any meetings. She has provided some information as to how she intends to address this. The provision of supervision for all members of staff provide the necessary safeguards to ensure that the delivery of care to service users is consistent and good. This home has had a significant number of new staff since the previous inspection. Their supervision should have been an integral part of their induction. There has been acknowledgement in writing by the Registered Manager that she has been remiss in not providing supervision and has stated her intention to improve upon this. 2 Dunstans Drive DS0000051745.V307446.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. The Registered Manager is qualified and experienced to manage the home. There are policies and procedures in place to safeguard both service users and members of staff. Quality assurance systems are in place however, it is important to evidence that deficits have been addressed. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Registered Manager is qualified and experienced to run the home. She has provided evidence to demonstrate that she undertakes periodic training to improve her knowledge and skills. The home does have quality assurance and quality monitoring systems in place. During the inspection process the Regulation 26 notifications completed by the representative of the Responsible Individual were reviewed. It was evidenced that issues have been highlighted by these visits, for example, the 2 Dunstans Drive DS0000051745.V307446.R01.S.doc Version 5.2 Page 21 need to review care plans have not been initiated by the Registered Manager or reviewed by the person completing the monitoring visit. This is an issue that the representative of the Responsible Individual might wish to consider for review following future visits. The evidence from the pre-inspection questionnaire and the training completed by members of staff indicates that the health, safety and welfare of service users are promoted and protected. 2 Dunstans Drive DS0000051745.V307446.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 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X 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 2 2 X 3 X 2 X X 3 X 2 Dunstans Drive DS0000051745.V307446.R01.S.doc Version 5.2 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement Timescale for action 30/11/06 2 YA7 12(2) 3 YA9 13(4) The Registered Manager must review all the care plans for the service users to ensure they are up-to-date and accurate. The care plans should be dated and signed and reviewed regularly either, to reflect the changing needs of the service users or at least every six months. Consultation with the service users or their representatives should occur and all revisions to the care plans notified to all concerned. Members of staff must be familiar and have access to the most current information about service users needs. The Registered Manager must 30/11/06 ensure the information about service users relatives and their representatives is kept up to date and recorded in the care records. These are the people who act as the “voice” of the service users in this home. The Registered Manager must 30/11/06 ensure that all risk assessments for service users are up-to-date and accurately reflect the current situation. All risk assessments DS0000051745.V307446.R01.S.doc Version 5.2 2 Dunstans Drive Page 24 4 YA24 23(2)(c) 5 YA36 18(2) should be signed, dated and reviewed regularly. All members of staff should be familiar with the current risk assessments for all service users. The Responsible Individual ensures that the provision of a kitchen that meets the health and safety needs of the members of staff is achieved. The Responsible Individual should also ensure that the refurbishment of the shower room is achieved promptly. The Registered Manager ensures that all staff receive regular, recorded supervision from appropriately trained staff. THIS IS A REPEATED REQUIRMENT. 30/11/06 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA19 YA20 Good Practice Recommendations The Registered Manager ensures that the proposals to reassess the physiotherapy and occupational therapy needs of some of the service users are implemented. The Registered Manager acquires a copy of the current regulations and guidance issued by the Royal Pharmaceutical Society of Great Britain to ensure compliance with best practice particularly with regard to controlled medicines. The Registered Manager ensures that the risk assessment for the garden area is updated and reviews whether some paving slabs need relaying because of an uneven surface. The Registered Manager considers the use of red alginate bag to transport soiled laundry from the service users rooms to the laundry areas. The Registered Manager ensures that photographs kept of DS0000051745.V307446.R01.S.doc Version 5.2 Page 25 3 3 4 YA24 YA30 YA34 2 Dunstans Drive 5 YA39 staff are clear enough to ensure that their likeness can be verified with the image. That the representative of the Responsible Individual ensures that the actions recommended following Regulation 26 visits to the home are reviewed to ensure they have been completed. 2 Dunstans Drive DS0000051745.V307446.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 2 Dunstans Drive DS0000051745.V307446.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!