Inspection on 03/10/06 for 24 Surrenden Road

This inspection was carried out on 3rd October 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

24 Surrenden Road 07/08/07

24 Surrenden Road 06/02/06

24 Surrenden Road 21/11/05

24 Surrenden Road 21/02/05

24 Surrenden Road 07/09/04

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Thorndene

Insight - Eastchurch

Southfields

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33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 24 Surrenden Road Brighton East Sussex BN1 6PP Lead Inspector Nigel Thompson Unannounced Inspection 3rd October 2006 09:00 24 Surrenden Road DS0000014123.V309567.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 24 Surrenden Road DS0000014123.V309567.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. 24 Surrenden Road DS0000014123.V309567.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 24 Surrenden Road Address Brighton East Sussex BN1 6PP 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) 01273 504344 Hallcreed Limited Julia Brooks Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 24 Surrenden Road DS0000014123.V309567.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is three (3). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. Date of last inspection 6th February 2006 Brief Description of the Service: 24 Surrenden Rd is registered with the Commission for Social Care Inspection (CSCI) to provide residential care and support for up to three people with learning disabilities. The home is situated in a pleasant residential area of Brighton, close to local parks, shops and pubs. It is convenient for bus services into the city centre and other areas, and is close to Preston Park station. The home does not provide nursing care. The current service users have lived in the home for many years. The building is a two-storey house with accommodation on both floors. It is not suitable for mobility problems. There is a garden to the rear of the property on the road outside. Service users have the use of the lounge and a large kitchen/diner and also the hydrotherapy pool located in one of the other properties owned by Hallcreed Limited. Information about the service, including the recently updated Statement of Purpose, Service User’s Guide and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. The current range of fees at 24 Surrenden Road, as of 3 October 2006, is £88.50 - £98.85 per day. Additional charges are made for hairdressing, certain activities, magazines, toiletries and holidays. 24 Surrenden Road DS0000014123.V309567.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four and a half hours in October 2006. It found that the majority of the National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Service users spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. On the day of the inspection there were three service users living at the home. The inspection involved a tour of the premises, observation of working practices, examination of the home’s records and discussion with the service users and the Registered Manager. Responses from a CSCI service users’ survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. The focus of the inspection was on the quality of life for people who live at the home. What the service does well: What has improved since the last inspection? Since the previous inspection, individual care plans have been amended to include details of how staff deal consistently with challenging behaviour. 24 Surrenden Road DS0000014123.V309567.R01.S.doc Version 5.2 Page 6 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. 24 Surrenden Road DS0000014123.V309567.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 24 Surrenden Road DS0000014123.V309567.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): 1, 2, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Documentation, including a comprehensive ‘Statement of Purpose’ and ‘Service Users’ Guide’ ensures that prospective service users and their relatives have sufficient information about the home and the services provided. The thorough admission policy and procedure ensures that service users are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. EVIDENCE: Although the manager confirmed that there have been no admissions to the home for over fifteen years, it was noted that there is a clear admission policy and procedure in place. Comprehensive information is made available to all prospective service users and it was noted that the quality and accessibility of the home’s ‘Statement of Purpose ‘ and the ‘Service User Guide’ is further enhanced by effective use of illustrations. It was noted that both of these documents have been reviewed and amended since the previous inspection to reflect the managerial changes that have taken place. 24 Surrenden Road DS0000014123.V309567.R01.S.doc Version 5.2 Page 9 Following a referral to the home, the manager will visit the prospective service user and carry out a pre-admission needs assessment, including any personal care needs, mobility issues, social and cultural needs and family involvement. After discussion with the manager, it is recommended that the current preadmission format be reviewed and amended to be more detailed and include more specific and useful information than: ‘Walk - ‘yes’ or ‘no’. In addition to establishing whether the individual’s care and support needs can be met within the home, the manager also stressed the importance of ensuring compatibility with existing service users. For individuals referred through Care Management arrangements, the manager confirmed the need for a completed Social Care Assessment being provided. All prospective service users have the opportunity to visit the home to look around and meet with existing residents and staff before moving in. 24 Surrenden Road DS0000014123.V309567.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 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 good. This judgement has been made using available evidence, including a visit to this service. Comprehensive care plans enable staff to meet the assessed support needs of service users in a structured and consistent manner. Systems for consultation and participation are effective. Service users are treated with respect and encouraged and enabled to make decisions about their day-to-day living. EVIDENCE: Service users care plans that were examined showed clear evidence of annual community reviews and of interim six monthly ‘in-house’ reviews. However there was no recorded evidence of who was present at the review meeting. Certain individual programme plans were dated and, where appropriate, signed by the service user, to agree the content and any changes. However this was not the case in all plans and it is evident that there is some inconsistency in how service user’s files are currently being maintained. The manager confirmed that improvements in the content and organisation of service users’ care plans and information files is ‘work in progress’. 24 Surrenden Road DS0000014123.V309567.R01.S.doc Version 5.2 Page 11 It was noted that each service user’s care plan contained an impressive and informative summary of the past year, compiled by the individual service user, their key worker and the manager. The manager confirmed that service users are consulted regarding many aspects of their day-to-day living, including choosing colour schemes for their room and communal areas, menu planning, recreational and leisure activities and holidays. This was supported through discussions with service users, spoken with during the inspection: ‘My room is next to be decorated and I have already chosen the colour I want’. 24 Surrenden Road DS0000014123.V309567.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 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. This judgement has been made using available evidence, including a visit to this service. Service users are enabled and supported to maintain contact with family and friends as they wish and effective links with the community enrich their social and educational opportunities. Service users benefit from appropriate recreational and leisure activities and menus that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: The recreational and leisure interests of service users are identified and recorded in their individual care plan, as part of the initial assessment process. It was evident that activities, including college courses, visiting garden centres and friends and shopping, reflect these interests and effectively meet service users’ individual and collective social care needs. Service users spoken with during the inspection were clearly enthusiastic about their individual day services: 24 Surrenden Road DS0000014123.V309567.R01.S.doc Version 5.2 Page 13 ‘I like my college. I do ‘Shop. cook and eat’ and ‘Singing and rhythm’. The manager confirmed that visiting at the home is unrestricted and service users may see their friends or relatives in the lounge or in the privacy of their own room. Where appropriate, links with family and friends are encouraged and supported. Menus are varied and balanced and are based on service users’ identified likes and preferences. An alternative to the main meal is always available and the ‘flexible’ four-week menu is regularly discussed with service users. The manager confirmed that service users are not generally involved in meal preparation. Although there is clearly effective communication within the home and good interaction between the service users, following discussion with the manager, it is recommended that a regular structured service user and staff meeting be reinstated, with minutes taken. 24 Surrenden Road DS0000014123.V309567.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 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. This judgement has been made using available evidence, including a visit to this service. Staff have developed close and positive relationships with service users and demonstrate an awareness and sound understanding of their individual care and support needs. Service users are protected by clear and comprehensive policies and procedures in place for the control and safe administration of medication. EVIDENCE: In accordance with their care plan, service users are fully supported and enabled, as far as practicable, to exercise control over their lives and maintain maximum levels of independence and individuality. During the inspection, staff were observed interacting with service users in a professional and respectful manner. Documentary evidence was in place to demonstrate that the health and emotional care needs are continuing to be met within the home. All service users are registered with local GPs and have access to other health care professionals, including district nurses, physiotherapists and dentists, as 24 Surrenden Road DS0000014123.V309567.R01.S.doc Version 5.2 Page 15 required. It was noted, in care plans that were examined, that all appointments with, or visits by, health care professionals are recorded. The manager confirmed that close and effective working relationships between service users and their key worker ensured that any subtle change in a resident’s mood or behaviour could be picked up on and addressed at an early stage. Policies and procedures, relating to the control and administration of medication, are in place and were found to be accurate, well maintained and up to date. The manger confirmed that staff directly involved in these procedures receive appropriate training. The home operates a ‘Monitored Dosage System’ (MDS) and regular monitoring of procedures as well as guidance and advice is provided by a local pharmacist. 24 Surrenden Road DS0000014123.V309567.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 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 adequate. This judgement has been made using available evidence, including a visit to this service. The lack of an accessible and up to date complaints procedure does not ensure that service users, staff and visitors feel able to express any concerns and service users are at potential risk from inadequate and outdated policies and procedures relating to abuse and adult protection. EVIDENCE: There is currently no accessible or satisfactory complaints procedure in place, for the benefit of service users’ relatives or other visitors to the home and the manager was unable to provide such a document for inspection. It was noted that in the policy file, outdated guidance was available for staff on how to deal with a complaint from a visitor to the home. However this does not constitute a complaints procedure and, in line with the majority of the home’s policies, the complaints policy is required to be reviewed and updated. For the benefit of service users living in the home, a simple illustrated complaints procedure has been developed, with the use of symbols. The manager confirmed that due to the variable levels of mental capacity among the service users, it is unclear as to the individual awareness or understanding of the process. It was noted that no complaints have been received by the home since the previous inspection. 24 Surrenden Road DS0000014123.V309567.R01.S.doc Version 5.2 Page 17 The home has inadequate and outdated policies and procedures on adult protection and there was no evidence of a ‘Whistle Blowing’ procedure having been developed. The manager confirmed that staff are made aware of relevant policies and procedures relating to abuse and adult protection through their induction training. She also added that all staff are due to attend relevant Adult Protection training, which focuses specifically on identifying different forms of abuse and procedures for alerting. However there was no documentary evidence that staff receive the appropriate guidance, as relevant staff training records were not made available for inspection. 24 Surrenden Road DS0000014123.V309567.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 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 adequate. This judgement has been made using available evidence, including a visit to this service. The service is accessible, generally safe and clean and remains suitable for it’s stated purpose. Service users benefit from pleasant accommodation that is comfortable and generally well maintained, however the current state of the kitchen is unsatisfactory and certain areas throughout the home are in need of redecoration. EVIDENCE: It is evident that there has been little change in the physical environment at 24 Surrenden Road since the previous inspection and standards remain generally satisfactory throughout. The premises, including the lounge, conservatory, kitchen, dining area and large garden are accessible, safe and clearly meet their stated purpose. During my ‘guided tour’ of the premises it was evident that the reasonably well maintained décor and adequate furniture and furnishings continue to provide a comfortable, pleasant and homely environment for service users. 24 Surrenden Road DS0000014123.V309567.R01.S.doc Version 5.2 Page 19 The manager confirmed that the currently neglected looking kitchen and dining area is due to be totally redecorated and refurbished in the near future, with replacement units and a new floor covering. Many radiators throughout the building were found to be rusty and clearly showing signs of wear and tear. Following discussion with the manager, it is recommended that the repainting or upgrading of the radiators be included in the ongoing maintenance programme for the home. To ensure the safety of service users, it is also required that risk assessments be carried out regarding the possible need for radiator covers, in respect of two service users who have been diagnosed with epilepsy. The manager confirmed that independence and individuality continue to be promoted within the home and this is evident from the personalising of service users’ individual rooms, which clearly reflects individual tastes and interests. It was noted that infection control policies and procedures are in place and clearly adhered to. A daily cleaning rota is evidently in place for individual rooms, which staff are expected to sign off when the work is completed. Levels of cleanliness remain satisfactory throughout. 24 Surrenden Road DS0000014123.V309567.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. There is not always sufficient trained and competent staff on duty to meet the assessed needs of the service users. However, service users are protected by satisfactory staff recruitment policies, procedures and documentation. EVIDENCE: There are concerns regarding the minimal staffing levels operated within the home and the potential impact this has on the care and support of service users, as well as the inevitable affect on their social and recreational opportunities. The manager confirmed that there was often only one member of staff on duty, both mornings and evenings, as well as at weekends. As discussed, this situation is unsatisfactory and clearly does not always ensure that the assessed needs of service users are being met, or that their best interests being served. The manager did confirm that, in line with other homes within the group, the matter is being addressed and additional staff are currently being recruited, through the organisation’s head office. 24 Surrenden Road DS0000014123.V309567.R01.S.doc Version 5.2 Page 21 It was noted in his ‘Person Centred Plan’ that one service user had commented on the need for everyone to go out together, due to there being only one member of staff on duty: ‘I can find it frustrating when someone does not want to go out’. ‘I need help to understand why I cannot go out all the time’. When service users are out at college or day centres the home is often left unstaffed during the day. However the manager described the ‘on call’ system that is in place, with staff from another home being available if needed between 9.00am and 5.00pm. Management level ‘on call’ cover is provided outside of ‘office hours’ and is detailed on the rota. Staff have suitable job descriptions and a sample of these was made available for inspection. Staff confirmed that they have contracts of employment and that they are familiar with the General Social Care Council’s code of conduct, and a copy was available in the home. A current duty rota was made available for inspection. However it is recommended that the designation of staff on duty at any time be recorded. A welcome development, are the recently implemented and impressive training folders, now in place in respect of the manager and one member of staff. Evidently, the organisation’s training officer has produced the folders and it is understood that similar files are to be provided for all staff. It was noted that, with the exception of the manager, there are currently no staff working in the home who have achieved NVQ level 2 in care. Staff recruitment records, although not held in the home, were made available and inspected at a later date at the head office. Individual files that were examined, relating to recently appointed members of staff, were found to be well maintained, containing all relevant and necessary information, including two satisfactory references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. 24 Surrenden Road DS0000014123.V309567.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 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 adequate. This judgement has been made using available evidence, including a visit to this service. Service users benefit from a well run home and are protected by satisfactory health and safety procedures. However their best interests are not safeguarded by ineffective quality monitoring systems and out of date policies and procedures. EVIDENCE: A new ‘unit manager’ took over at 24 Surrenden Road in March this year and she has subsequently been registered with the CSCI. She is clearly competent to run the service and has achieved NVQ level 4, in Management and Care. The home continues to use a pictorial satisfaction feedback chart for service users to demonstrate how they are feeling about the service they receive. Evidence was in place of a recent survey having been carried out in July this year with responses indicating a general level of satisfaction with the care and 24 Surrenden Road DS0000014123.V309567.R01.S.doc Version 5.2 Page 23 support provided. Following discussion with the manager and in view of their variable levels of communication, it is recommended that feedback from service users’ relatives and stakeholders in the community also be sought formally from time to time. Files for policies and procedures that were examined were found to be disorganised and poorly maintained. Many policies were also found to be generic and relate to the wider organisation. There was also evidence that policies are not routinely being reviewed and updated, as required. The manager confirmed that the health, safety and welfare of service users and staff remain of paramount importance within the home. She added that training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. However, as previously recorded, inadequate staff training records were not able to support this. COSHH assessments and guidelines are in place. Regular fire drills are undertaken and recorded. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and reported, as required. 24 Surrenden Road DS0000014123.V309567.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 3 2 3 3 3 4 3 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 3 32 2 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X 24 Surrenden Road DS0000014123.V309567.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA22 Regulation 22 (8) Requirement It is required that an accessible complaints procedure is developed and that a record is maintained of all complaints received, including details of any investigation, action taken and the outcome. It is required that service users be protected from potential abuse by appropriate staff training and relevant and up to date policies and procedures. It is required that radiators be covered or risk assessments carried out, in respect of service users at risk of falling. It is required that sufficient qualified and competent care staff are on duty at all times to meet the assessed needs of service users. It is required that quality monitoring systems be improved by seeking the views of service users’ relatives and other stakeholders. Timescale for action 31/12/06 2. YA23 13 (6) 30/11/06 3. YA24 13 (4) 30/11/06 4. YA35 18 (1) (a) 30/11/06 5. YA39 24 (1) (3) 31/12/06 24 Surrenden Road DS0000014123.V309567.R01.S.doc Version 5.2 Page 26 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 YA2 Good Practice Recommendations It is recommended that the current pre-admission format be reviewed and amended to be more detailed and include more specific and useful information than: ‘Walk - ‘yes’ or ‘no’ etc. It is recommended that a regular structured service user and staff meeting be reinstated, with minutes taken. It is recommended that the repainting or upgrading of the radiators be included in the ongoing maintenance programme for the home. It is recommended that 50 of care staff obtain NVQ level 2 in care. 2. 3. 4. YA16 YA24 YA32 24 Surrenden Road DS0000014123.V309567.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 24 Surrenden Road DS0000014123.V309567.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. 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