Inspection on 06/07/06 for 24a Corporation Road

This inspection was carried out on 6th July 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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

24a Corporation Road 30/05/07

24a Corporation Road 31/01/06

24a Corporation Road 04/07/05

24a Corporation Road 03/03/05

24a Corporation Road 04/01/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 24a Corporation Road Chelmsford Essex CM1 2AR Lead Inspector Jane Greaves Key Unannounced Inspection 6th July 2006 09:30 24a Corporation Road DS0000017731.V302625.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 24a Corporation Road DS0000017731.V302625.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. 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 24a Corporation Road Address Chelmsford Essex CM1 2AR 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) 01245 495010 Redbridge Housing Association Frances Elizabeth Beard Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (2), Physical disability (4) of places 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Eight persons of either sex, under the age of 65 years, who require care by reason of a learning disability, of whom four also have a physical disability. Two persons of either sex, aged 65 years and over, who require care by reason of a learning disability, whose names were made known to the National Care Standards Commission in June 2003. The total number of service users accommodated in the home must not exceed 8 persons 31st January 2006 Date of last inspection Brief Description of the Service: 24a, Corporation Road is a modern, purpose built, single storey property situated in a quiet residential area close to Chelmsford town centre. The property is divided into two separate living units each with four single bedrooms, bathrooms, toilets and communal facilities. The home provides accommodation and care for 8 adults with learning disabilities and physical disabilities who have medium to high dependency needs. The home aims to empower service users to maximise their independence and to integrate into the local community. Specialist equipment, including baths and hoists, are provided and all bedrooms are suitable for wheelchair users. The grounds are private and secure with adequate parking facilities available to the front of the property. The home is situated on a bus route although the town itself is within walking distance. The registered proprietor is Redbridge Community Housing Limited, a voluntary organisation. A copy of the previous inspection reported produced by the Commission for Social Care Inspection was accessible to service users, visitors and staff members. Due to the manner in which the fees are broken down the service was not able to provide precise information regarding the range of fees payable for the care, support and accommodation package. 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key Inspection took place on 6th July 2006 over 6 ½ hours. 24 of the 43 National Minimum Standards were assessed and 13 were met. Views of the service were gathered from discussion with 4 service users and 3 visiting family members. Documents were sampled and records provided by the manager since the previous inspection visit were used as part of this inspection process. The management of the service had changed since the previous inspection visit; the newly appointed manager had started the process of registering with the Commission for Social Care Inspection. This inspection report includes some outstanding requirements made at the previous inspection visit. Some requirements remain outstanding however there had been progress made towards compliance and evidence was available to confirm ‘work in progress’ in these areas. The inspector appreciated the assistance and co-operation from service users, the staff and the management team at this visit. What the service does well: What has improved since the last inspection? At the last inspection visit the service users’ ‘activities’ room contained little evidence of service users’ activities and recreation but contained the home’s computer and a filing cabinet. At this visit it was reported that the room was still used for staff meetings, shift handovers and training, however there was evidence that service users had been able and encouraged to use this space. Since the previous inspection visit all staff members had received training in the Protection of Vulnerable Adults. 24a Corporation Road DS0000017731.V302625.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. 24a Corporation Road DS0000017731.V302625.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 24a Corporation Road DS0000017731.V302625.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 outcome in this area is good. This judgement has been made using the available evidence including a visit to this service. A robust assessment process ensured that prospective service users’ individual needs were assessed before they made the decision to enter the home permanently. EVIDENCE: The file of a new service user was assessed at this visit. A robust preadmission assessment undertaken by the service was present together with the social services needs assessment and reports from other involved agencies. The pre-admission assessment made on behalf of the service involved the prospective service user, a family member or representative, the relevant social worker and the manager of the home. These documents provided detailed information regarding the individual’s physical, emotional, social needs and preferences. Assessments of potential risks to the prospective service user’s health, safety and well being were undertaken during the preadmission assessment process. Any restrictions on individual’s rights or responsibilities were documented with the reason for the infringement and evidence that the service user had been involved and understood the process. Evidence was available to confirm that the prospective service user was offered trial visits varying from an afternoon visit to staying for a few days. Established residents at 24a, Corporation Road were actively involved with the process of selecting a new person to share their home. 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 9 The service provides prospective service users with a Statement of Purpose and a Service User Guide detailing the facilities, support and personal care to be provided at 24a, Corporation Road. 24a Corporation Road DS0000017731.V302625.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 and 9 Quality outcome in this area is good. This judgement has been made using the available evidence including a visit to this service. The service supports and encourages individuals to make life decisions and provides the information and opportunity to take risks as part of daily life. EVIDENCE: Two service users’ care plans were selected for inspection at this visit. The care plan for a recent admission into the service had not been developed from the pre-admission assessment documents at the time of this visit. Support staff provided care and support for this person with the aid of the information provided in the assessments. Daily records confirmed that care had been provided in accordance with the assessed needs. The care plan of an established service user contained evidence of regular in depth reviews of physical, social and emotional needs and details of healthcare practitioner appointments attended. The service user, their relatives, a social worker, the key worker assigned to the service user and any relevant healthcare professionals were involved in the development and review of the service users’ care plans. Any restrictions on individuals’ choices and freedom 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 11 were clearly documented with evidence of the service users’ involvement and agreement. A copy of the contract between the service provider and the service user detailing rights, responsibilities and expectations of both parties was included in the file sampled. The staff and management team provided support and information for service users to make informed decisions about their own lives. All the service users at 24a, Corporation Road had family members to support and represent them; the manager reported that advocacy services would be sought for any service user who did not have this support. The ethos of the service supported individuals to take responsible risks within the context of their individual plan of care and the home’s risk management strategies. Assessments of risk were seen for activities such as horse riding, self-medication and challenging behaviour to other residents. Whilst it was evident from conversation with the staff team and observation of practice that these risks were reviewed on a continuous day by day basis documentation did not confirm this. 24a Corporation Road DS0000017731.V302625.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, 14, 15, 16 and 17 Quality outcome in this area is good. This judgement has been made using the available evidence including a visit to this service. Residents enjoyed their life experiences both inside and outside the home. EVIDENCE: No service users at 24a, Corporation Road undertook paid employment, however one service user engaged in voluntary work in the community. All service users were supported to be independent and were encouraged to take part in activities within the home and the local community. Some activities enjoyed by the service users included horse riding, bowling, attending college and day centres, narrow boat trips, visiting the butterfly farm, attending Church and taking annual holidays. It was reported that one service user had ceased to do all activities they had enjoyed previously within the the home however staff had encouraged, motivated and supported this person to regain confidence and recommence some activities both inside and outside the home. Service users contributed from their mobility allowance to fund the project vehicle. 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 13 Previous inspection reports had identified that the service users had not received an annual 7 day break away from the home as part of the basic contract price. Some service users had enjoyed a holiday away from the service this year, the service provider’s contribution was the staff wages, and the service user provided funding for the holiday and the accommodation for the supporting staff. It was reported that the service provider had this issue currently under review. The manager reported that the home operated an ‘open door’ policy for service users’ family members provided the service users gave their consent. Family members were invited on an individual basis to parties at the unit. During this inspection visit 3 service users had visits from family members. Relatives reported being made very welcome at any time and praised the home for the way they were kept informed and involved regarding their loved ones’ care. It was reported that the home did not operate under ‘daily routines’ but that life was arranged around the individuals’ needs and choices. Some service users had a key to their bedroom and to the front door of the home. The manager reported there were no instances where a service user’s mail was opened in their absence, those with cognitive impairments received support to read and understand their mail and then to make decisions as to how to respond. Some service users were involved with cleaning their rooms with support from staff members. Mealtimes were flexible around the various activities taking place daily. It was reported that breakfast and lunch were taken on an individual basis with the evening meal enjoyed sociably together where possible. Service users chose the weekly menu however it was reported, and daily records confirmed, that where individuals did not fancy the planned meal an alternative option was provided. The kitchens in both houses were suitable for purpose and in working order. The food stocks seen were appropriate to the menu and of good standard. It was reported that refresher basic food hygiene training for staff members was booked for this month. One service user reported they helped to prepare meals occasionally and support staff assisted another with cake baking, appropriate risk assessments were in place for these activities. 24a Corporation Road DS0000017731.V302625.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 and 20 Quality outcome in this area is good. This judgement has been made using the available evidence including a visit to this service. Staff respected service users’ preferences about their personal needs when providing support and intimate care. EVIDENCE: Observation of the care practice on the day, discussion with staff and service users and scrutiny of care plans all provided evidence to confirm that the service users received care in accordance with their assessed needs and preferences. Personal care was provided in private and where the care plans identified that care should be delivered by a person of the same gender the staff rotas confirmed this was practicable. Care plans confirmed that when a need for specialist support and advice was identified the service user was supported to access this. Each service user had a designated key worker to ensure continuity and consistency of the care provision. The service users received support to access NHS healthcare facilities in the locality. Individuals’ health was monitored to identify potential complications and problems; evidence was available to confirm instances of referral to appropriate specialists. 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 15 No service users at 24a, Corporation Road retained or administered their own medication or were prescribed controlled drugs. Medicines were stored in a locked cabinet secured to the office wall, the recording of medicine administration was appropriate with no gaps on the recording sheet. The staff team had not received refresher medication training. Medicine re-ordering was undertaken monthly; discussion took place with the manager regarding excess stocks of one medication held due to routine re-ordering. 24a Corporation Road DS0000017731.V302625.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 and 23 Quality outcome in this area is adequate. This judgement has been made using the available evidence including a visit to this service. Service users would be better protected if the home’s policies and procedures for dealing with complaints were adhered to. EVIDENCE: The home’s complaints folder contained evidence of a complaint received by the service in April 2006 however there was no audit trail of actions taken. It was reported that this issue was being addressed and the organisation was aware that in this instance actions had not been taken within the timescales of the home’s complaints policies and procedures. All service users spoken with at this visit were confident that if they wished to make a complaint or raise a concern their voices would be heard and they would be taken seriously. It was evident from observation at this visit that the staff and management team at 24a, Corporation Road operated an ‘open door’ policy for service users and families alike. Everyone felt comfortable putting their head round the office door or approaching one of the team around the building to ask a question or just chat. The home operated under Redbridge Community Housing Limited robust policies and procedures for adult protection. Most of the staff team had received training in the protection of Vulnerable Adults from Abuse; the remainder were due to undertake this training the week following this visit. Recruitment procedures included obtaining an enhanced criminal records bureau disclosure for all staff members before they commenced working at the home. One recruitment file sampled as part of this inspection visit did not contain all items as specified in regulation. 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality outcome in this area is adequate. This judgement has been made using the available evidence including a visit to this service. Service users lived in a comfortable home maintained to a satisfactory level of cleanliness and hygiene. EVIDENCE: A physical tour of the building was undertaken as part of this inspection visit, the premises were found to be safe and accessible for the people living there. The previous inspection report identified that lounge and hallway carpets in house one were stained, an overhead hoist in a bathroom in house one was out of order and a bathroom floor in house two appeared ‘grimy’. These issues remained outstanding at this visit. The outstanding areas for improvement of the service users environment were discussed with the manager and a representative of Redbridge Community Housing Limited, it was reported that the flooring in these rooms was due for imminent replacement. The previous inspection report identified that the service users’ activities room was being used as additional office space and staff meeting and training room. The room appeared more informal, relaxed and service user orientated at this 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 18 visit although one resident was happily eating their lunch in this room when they were asked to vacate in order that a fellow service user’s review could take place there. Staff meetings, shift handover sessions and staff training still took place in this room as there was no other space available at the unit. A filing cabinet and computer remained in this room. Discussions were held with the manager around the provision of specialist computer programmes for the service users’ use. The manager reported the intention to discuss this space and its potential uses with the service users at the next house meeting. Service users’ personal rooms were pleasantly decorated and personalised, communal hallways, lounges and dining rooms generally appeared fresh, bright and homely. The rear garden at 24a, Corporation Road was large with some pleasant trees and a seating area. It was reported that the service users chose not to spend time in the garden; methods of using this valuable resource and creating an inspiring space for service users were discussed with the manager and a representative of Redbridge Community Housing Limited. Staff reported that there were plans to create a shaded ‘sensory’ area with aromatic plants and wind chimes. Overall the unit appeared clean and fresh at this visit with no unpleasant odours. The staff team had not received training in the control of infection. 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality outcome in this area is adequate. This judgement has been made using the available evidence including a visit to this service. Despite a lack of a planned and scheduled training provision the service users received good care and support from a dedicated, motivated and knowledgeable staff team. EVIDENCE: Two staff files were sampled at this inspection. One file contained all documents to evidence that appropriate recruitment checks had been made and the home’s recruitment policies and procedures had been followed. One file did not contain an application form, written references or a record of induction training undertaken. The service did not have a clear, budgeted training and development programme to evidence that all staff would receive the mandatory training and training specific to the needs of the service user group. The new manager in post reported the intention to oversee all staff training needs as a priority. Records were not available to confirm attendance of some areas of mandatory training however the manager was able to demonstrate where courses had been booked to address this shortfall. Records confirmed that training and development were discussed at regular staff supervision sessions. 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 20 It was reported that the organisation’s training brochure was issued in May but did not arrive until July. Staff reported that this caused difficulty as some of the courses had taken place before the brochure reached the homes. The staff team did not demonstrate awareness of which areas of training were mandatory. 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality outcome in this area is adequate. This judgement has been made using the available evidence including a visit to this service. The service users benefited from the open and positive ethos of the home, however their health and safety would be better protected by the provision of mandatory training and annual refresher training for the staff team. EVIDENCE: At the time of this inspection the new manager had not applied to be registered with the Commission for Social Care Inspection. The manager had management and supervisory experience in care settings and was undertaking the Registered Managers Award. The previous inspection report for this service identified that a Quality Assurance review was undertaken by the organisation annually however the results were not available. Discussions took place regarding a specific annual service audit involving the service users, their families and representatives, staff and other stakeholders. The monthly regulation 26 reports submitted to 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 22 the commission were detailed and informative providing information as to which outcome groups had been addressed, what the findings were and what actions were to be taken to address any identified shortfalls in the service provision. The reports confirmed service user involvement with all aspects of daily life at 24a, Corporation Road. Family members were actively encouraged to be involved at the home and all visitors spoken with confirmed they were happy with the service their loved ones received. The mandatory training required for the protection for the health, safety and well being of the service users had not been provided for all staff members. Evidence was available to confirm the safe maintenance of the building and electrical systems and records of water temperature and fridge temperature checks were available. Safety procedures were posted in a format relevant to service users’ needs. Discussions with staff confirmed their awareness of COSHH policies and procedures. The previous inspection report for this service identified that a Quality Assurance review was undertaken by the organisation annually however the results were not for submission to the commission. Discussions took place regarding a specific annual service audit involving the service users, their families and representatives, staff and other stakeholders. The monthly regulation 26 reports submitted to the commission were detailed and informative providing information as to which outcome groups had been addressed, what the findings were and what actions were to be taken to address any identified shortfalls in the service provision. The reports confirmed service user involvement with all aspects of daily life at 24a, Corporation Road. Family members were actively encouraged to be involved at the home and all visitors spoken with confirmed they were happy with the service their loved ones received. The mandatory training required for the protection for the health, safety and well being of the service users had not been provided for all staff members. Evidence was available to confirm the safe maintenance of the building and electrical systems and records of water temperature and fridge temperature checks were available. Safety procedures were posted in a format relevant to service users’ needs. Discussions with staff confirmed their awareness of COSHH policies and procedures. 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 23 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 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 X 33 X 34 2 35 2 36 3 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 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X 2 2 X 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 24 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(1) Requirement Timescale for action 2. YA20 18(1)(c) 3. YA22 22(8) The registered person shall, after consultation with the service 31/07/06 user, or a representative of his, prepare a written plan (the service user’s plan) as to how the service user’s needs in respect of his health and welfare are to be met. 31/10/06 The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of the service users ensure that persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform. This specifically refers to medication refresher training. The registered person shall 31/08/06 supply to the Commission on request a statement containing a summary of the complaints made during the preceding twelve months and the action taken in response. This is a repeat requirement that did not meet the original agreed timescales DS0000017731.V302625.R01.S.doc Version 5.2 Page 25 24a Corporation Road 4. YA24 23(2)(c) 5. YA30 23(2)(d) 6. YA34 19(5)(d) 7. YA35 18(1)(c) 8. YA39 24 9. YA41 Sec31(4a) The registered person shall, having regard to the number and needs of the service users, ensure that equipment provided at the care home for use by service users or persons who work at the care home is maintained and in good working order. The registered person shall, having regard to the number and needs of the service users, ensure that all parts of the care home are kept clean and reasonably decorated. This specifically refers to stained carpeting and bathroom flooring. The registered person shall ensure full and satisfactory information is available in relation to all persons employed to work at the care home in respect of matters specified in schedule 2. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of the service users ensure that persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform. This specifically refers to mandatory and service specific training. The registered person shall supply to the Commission a report in respect of any quality review conducted by him and make a copy of the report available to service users. This is a repeat requirement that did not meet the original agreed timescales The registered person must ensure all records pertaining to DS0000017731.V302625.R01.S.doc 31/08/06 30/09/06 31/08/06 31/10/06 31/10/06 30/09/06 24a Corporation Road Version 5.2 Page 26 10. YA42 18(1)(c) the running of the care service are made available for scrutiny by the Commission for Social Care Inspection. This specifically relates to records held in relation to staff and Quality Assurance surveys. This is a repeat requirement that did not meet the original agreed timescales. The registered person shall, 31/10/06 having regard to the size of the care home, the statement of purpose and the number and needs of the service users ensure that persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform. This specifically refers to training in Health and safety. 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 YA14 Good Practice Recommendations The registered person should ensure that residents have the option of a 7 day break away from the home as part of the basic contract price. THIS IS A REPEAT RECCOMMENDATION. 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 24a Corporation Road DS0000017731.V302625.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!