Inspection on 07/02/07 for 26 Henley Way

This inspection was carried out on 7th February 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

26 Henley Way 19/03/09

26 Henley Way 28/02/06

26 Henley Way 23/08/05

26 Henley Way 02/02/05

26 Henley Way 13/10/04

26 Henley Way 19/03/04

26 Henley Way 30/09/02

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Henley Way (26) West Hallam Derby Derbyshire DE7 6LU Lead Inspector Tony Barker Key Unannounced Inspection 7th February 2007 09:30 Henley Way (26) DS0000020012.V328945.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 Henley Way (26) DS0000020012.V328945.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. Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Henley Way (26) Address West Hallam Derby Derbyshire DE7 6LU (0115) 9441946 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) None United Response Lorraine Hirst Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: 26 Henley Way is a detached house in a small village development. Service users are provided with adequate accommodation and single rooms. There is a reasonably-sized rear garden. The Home offers personal and social care to people with a severe learning disability with associated conditions that include autism and sensory disability. Activities are planned to meet individual needs. The fees currently range from £967.84 to £1085.53 per week. Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 7.5 hours and was a key unannounced inspection. The service users had high levels of dependency and therefore were not able to contribute directly to the inspection process, though they were observed working with and being cared for by staff. Survey forms were posted to all three service users. Support workers had attempted to help service users complete these but found that service users’ level of understanding was insufficient to grasp the nature of the questions. The Manager and one support worker were spoken to and records were inspected. There was also a tour of the premises. Two service users were case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The preinspection questionnaire was reviewed prior to this inspection. What the service does well: What has improved since the last inspection? The Home had acquired a new settee and television. One bedroom had been re-carpeted and a new mattress was in place. Perspex sheets had been fitted to the hall wall to prevent wheel chair damage. Recording practices, regarding service users’ records, had improved and this included better recording of the use of medicines. The frequency of staff training in fire safety had improved. Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 6 All of the requirements made at the last inspection had been met, though the need for a higher proportion of qualified staff has become a recommendation in this report. Four of the six recommendations made had 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. The summary of this inspection report can be made available in other formats on request. Henley Way (26) DS0000020012.V328945.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 Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users had their needs assessed before admission to the Home so that staff could provide individually tailored care. These needs were being regularly reviewed. EVIDENCE: The three service users at the Home were all admitted in the late 1980’s and no original documentation was available from that time. Service users’ files contained detailed assessments of need and individual care plans. These assessments and plans were being kept under review. Files also contained comprehensive and clearly thought through lists of potential restrictions on each service user’s ability to make choices, to have freedom of choice and decision making opportunities. Additional to these lists were statements relating to each service user’s limited involvement in the care planning process – though there was also reference to maximum opportunity being given to each person to express individual choice and be involved in decision making. Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were benefiting from a care planning system that centred on their individual needs and reflected changes in these needs. They were making decisions about their lives, with assistance, and were being supported to take risks to improve their independence. EVIDENCE: The Manager explained how the Home had introduced ‘Person-Centred Planning’ (PCP) into its care planning process. This involved identifying each service user’s individual likes, dislikes, aspirations and goals. There was a range of documentary evidence supporting this good practice. The new PCP file for one service user was examined – this was partially completed and its structure reflected a sound approach. Each service user had a ‘Behaviour Management Plan’ and the Manager described how these would be renamed in a more positive way, to reflect known behaviours, within the PCP approach. The Manager explained how recently introduced ‘Learning Logs’ facilitated the review of service user development through staff recording practices. A Learning Log for one of the case tracked service users was examined. Up-todate ‘Communication Profiles’ for each service user were examined and these Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 10 were comprehensive - providing an in-depth picture of each person’s personality, needs and behaviour. Each service user had an ‘Active Support Plan’ (ASP) for making a drink and this included the use of appropriate images. The Manager spoke of plans to extend these documents to all areas of activity and to involve service users in finding suitable images for these. The Manager pointed out that these ASP documents would cross-reference to recorded risk assessments. Monthly care plan reviews were examined for one case tracked service user. These were not being consistently recorded and some were not signed. The Manager stated that these reviews were already taking a PCP approach and provided evidence of this for another service user. This PCP review was to a good standard. All of the service users had difficulty communicating their needs and wishes although one service user had good comprehension abilities and does clearly make choices and decisions about everyday matters. The support worker, spoken to, said that this service user is more independent with regard to choosing clothes to wear and has shirts easily accessible in their wardrobe. She said that staff offer two items of clothing, such as T-shirts for instance, to other service users to enable them to make a choice. She gave other examples of service users making decisions and choices. A local advocacy agency had been providing a service to one service user for two years and had, recently, provided useful input into this service user’s PCP review meeting. Service users were involved in discussions with their key worker prior to care plan review meetings in order to ensure that their views were made known. They then attended these meetings. However, these pre-meeting discussions were still not being recorded on file. Other aspects of Standard 8 were not assessed on this occasion. There was evidence of recorded risk assessments being reviewed and updated. The Manager had introduced a new, streamlined risk assessment format intended to take the place of existing risk assessments. This had a well-considered structure but was not always easy to follow. There was discussion with the Manager as to ways of improving this, by highlighting topics. The support worker, spoken to, gave examples of service users taking responsible risks which develop them, personally. For example, two service users taking a holiday in Spain, and re-introducing one service user to swimming with staff. Henley Way (26) DS0000020012.V328945.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were involved in fulfilling and age-appropriate activities within the Home and in the local community. They engaged in satisfying leisure activities and were able to maintain appropriate relationships, where available. They were provided with a healthy personalised diet and daily routines reflected their individual choice and promoted independence. EVIDENCE: There was evidence of service users being involved in valued and fulfilling activities and of them being offered a number of new experiences. The support worker, spoken to, said that she knew service users did value certain activities by their facial and body expressions and noises individual to each of them. One case tracked service user had been interviewed by the local Council for Voluntary Service (CVS) for a voluntary post shopping for older people. The service user was due to make an application for a check by the Criminal Records Bureau (CRB). The Manager said this service user was excited about this new venture. She added that she was seeking a range of meaningful activities for all three service users in the light of the imminent closure of the Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 12 local United Response day services. At present all the service users were attending day services as well as one ‘personal day’ each week, spent one-toone with staff from the Home. The support worker, spoken to, described a number of activities undertaken by the service users in the local community. These included visits to local shops and pubs, swimming and bowling, and use of buses. Mention has already been made of two service users taking a holiday in Spain within the previous year. Also another service user had, at their own request, made a visit to Eurodisney and thoroughly enjoyed this, the Manager stated. She said that staff were particularly impressed by this service user’s positive reaction to this new experience, including the flight. The support worker, spoken to, said she was particularly rewarded by “being able to take service users to places not been before and seeing their enjoyment”. None of the service users had any personal contact with their family members, the support worker said. However, she added that one service user was “good friends” with a service user from a nearby care home. There was also some contact for service users from the ex-staff of the local establishment they had been admitted from. The support worker, spoken to, described routines in the Home that were assessed as being flexible. She said that all rise and go to bed at different times. One case tracked service user had a personal preference for rising later, during the week, and chose to have a later breakfast then. It was clear talking to staff that routines, within the Home, promote service users’ independence. All were involved in food shopping and clearing the table after mealtime and one case tracked service user was involved in preparing vegetables, making a packed lunch when attending day services and drying crockery. Food stocks were satisfactory and included fresh fruit and vegetables. The Home was operating a three-week rolling menu system. The menus provided with the pre-inspection questionnaire indicated that service users were receiving a varied and nutritious diet. The menu sheets made reference to “helping people prepare food to fit in with their own timetable, cook food that they want to eat at a time they want to eat it” and to take “individual likes and dislikes into account”. Details of meals actually eaten were being consistently recorded, as required at a previous inspection. Henley Way (26) DS0000020012.V328945.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. 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. Service users were receiving personal support in the way they preferred and required. Their health needs were being well met in an individualised way and they were being protected by the Home’s procedures for dealing with medicines. EVIDENCE: From observation and discussion with the Manager it was clear that service users’ communication needs had been assessed and, wherever possible, were being met. As an example, each resident had a communication board in their bedroom individualised to their own level of comprehension – photographs, pictorial or Makaton symbols. One service user had a sensory music centre in their bedroom and the Home had a sensory room. One case tracked service user was a wheel chair user and was due to have a replacement bath that could be used independently. There were a number of other technical aids in the Home for the use of service users with physical disabilities – including a rising bath seat, rollator walking aid and special cutlery and plates. The support worker, spoken to, was able to describe examples of how the Home was meeting service users’ privacy and dignity needs. For example, staff ensure that service users wrap a towel around them when moving between bathroom and bedroom and that doors are shut when the bathroom and toilet are in use. The support worker said, “I give each of them a few minutes on Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 14 their own (in the bath) to soak”. The Manager later confirmed there was a risk assessment in place to address this. The wheel chair user had their own bathroom. The atmosphere in the Home was relaxed at the time of this inspection and positive interactions between staff and service users were seen. Records supported that service users’ health was being monitored and ongoing health appointments were being recorded on ‘Medical Appointments’ sheets. Specialist services were also involved when needed. The Manager stated, for example, that there had been involvement from a physiotherapist, dietician, continence nurse and occupational therapist. All service users were attending the local ‘Well Man’ clinic. The Manager explained that future health appointments would be recorded on new documents called ‘My Health File’. These were small format ring files – one for each service user. These files include a body chart and the Manager said one service user would be able to point to a part of the body chart where they had a pain, for example. These files form part of the Home’s PCP approach. Service users’ medicine administration record (MAR) sheets were examined and good recording practices were noted. Photographs of service users were in place as was a sheet of sample signatures/initials of staff. Confirmation of medicines received was by means of two staff signatures. Medicines were being stored securely. The Manager confirmed that all staff had received training in the use of medicines – by the Home’s pharmacist and, for two staff, by an external trainer. Henley Way (26) DS0000020012.V328945.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were benefiting from the Home’s complaints policy and procedures and were being protected from abuse. EVIDENCE: The Home’s complaints procedure was displayed in the hallway and was satisfactory. Each service user had a ‘Picture Bank’ (pictorial) complaints procedure kept in their room. The Manager stated that there had never been any complaints received by the Home. The blank complaints record was in a good format. The Manager had attended a Derbyshire County Council training course on ‘Safeguarding Adults’ in 2005 as well as in-house training in 2006. United Response has an appropriate written procedure that is to be followed when there is suspicion of adult abuse. Derbyshire County Council written procedures and forms were in place. The support worker, spoken to, showed a good awareness of the Home’s ‘whistle blowing’ policy. All but two newly appointed staff had received ‘Safeguarding Adults’ training. Henley Way (26) DS0000020012.V328945.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were living in a comfortable and safe environment that was clean and hygienic. EVIDENCE: Since the previous inspection the Home had acquired a new settee and television. One bedroom had been re-carpeted and a new mattress was in place. Perspex sheets had been fitted to the hall wall to prevent wheel chair damage. The Manager spoke of plans for a full re-decoration of the premises and for a conservatory to be built. Two of the bedrooms were comfortable and personalised. The third bedroom was somewhat bare in appearance. All bedrooms had lockable doors. The laundry room had one washer, with a sluicing programme, and one dryer. The room was kept locked. The Home had a written infection control policy/procedure in place. It was clean and free from odours. Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were being supported by a staff group that, though adequately trained in certain mandatory topics, was not sufficiently qualified. Service users were protected by the Home’s recruitment procedures. EVIDENCE: 20 of the five care staff had achieved a National Vocational Qualification (NVQ) in Care to level 2 or above. This did not meet the National Minimum Standard to maintain a staff group with at least 50 qualified staff. The use of agency staff had dropped since the previous inspection, the Manager stated, and only one agency worker was being employed at the time of this inspection – giving continuity for the service user group. The Manager added that she keeps an eye on any excessive hours worked by staff. The Home was holding one 21.5 hour vacancy. Other aspects of Standard 33 were not assessed on this occasion. The file of a member of care staff appointed in June 2006 was examined. It was found to contain all of the elements, required by current Regulations, regarding recruitment practices. Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 18 There was documentary evidence of this same member of staff being provided with induction and foundation training to Learning Disability Award Framework (LDAF) standards, as recommended by Standard 35. This staff member said that her induction was a positive experience and gave details of the training she had received during the time she had been in post. Training records confirmed that all staff had been provided with all mandatory training. The pre-inspection questionnaire detailed a number of other courses undertaken by staff that addressed the individual needs of service users – as well as a good range of specialist courses planned for the future. Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were benefiting from a well run Home and their health and safety was being fully promoted. They were benefiting from an effective quality assurance system. EVIDENCE: The Manager had worked with adults with learning disabilities for nine years and had been registered to manage this Home as well as another United Response care home for 3 younger adults with learning disabilities, nearby. She had achieved an NVQ qualification in Care and Management at level 4 and the Registered Managers Award. There was a full-time post of senior support worker with additional responsibilities (SSWAR) at the Home. This post was designed to provide direct support to the Manager. The post holder’s hours included 12 each week working at the other, nearby, home and the SSWAR from that home provided 12 hours each week at this Home. This provided additional flexibility and further opportunities for joint working with the other home. Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 20 There was evidence of monthly audit visits to the Home being undertaken. However, only three of the last seven audit visits had been made by a person independent of the Home, on behalf of the Registered Provider, as required by Regulation 26. The other four audits had been made jointly by the Home’s Manager and SSWAR. The Manager reported that arrangements were now in place for all future audit visits to be undertaken by an independent person. The 2006/7 Service Plan for the Home was examined. This was well recorded and included timescales. It had been fully reviewed in November 2006. Quality assurance questionnaires, to assess opinions on the quality of service provided by the Home, had been sent to the advocate acting on behalf of the service users, to each service user’s social worker and to each care staff member working at the Home. The only response, so far, had been from the advocate, the Manager said. She spoke of plans to send quality assurance questionnaires to the Home’s handyman and to an ex-member of staff of the local establishment the service users had been admitted from, who had retained contact. External professionals had not been surveyed. Survey forms, for completion by service users, had been sent to the Home, by the Commission, prior to this inspection and staff had made every effort to enable service users to respond. However, this had not been possible due to their relatively limited levels of understanding. Good food hygiene practices were observed including the regular recording of refrigerator and freezer temperatures. Cleaning materials were being securely stored in the laundry room and kitchen – together with Control Of Substances Hazardous to Health (COSHH) product data sheets. The pre-inspection questionnaire, completed by the Manager, indicated that equipment was being serviced and checked at appropriate intervals. Fire alarm tests were carried weekly and fire drills were held monthly. The Manager said that monthly Health and Safety hazard checks were being made of each room in the Home. The Home’s environmental risk assessment was examined – it had been appropriately reviewed. No Health and Safety hazards were found at this inspection. Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 21 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 22 No 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. Standard Regulation Requirement Timescale for action THERE ARE NO REQUIREMENTS ARISING FROM THIS INSPECTION 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. 3. 4. 5. 6. Refer to Standard YA6 YA8 YA9 YA24 YA32 YA39 Good Practice Recommendations All records should be signed. (This was a previous recommendation) The outcome of discussion with service users prior to care plan review meetings should be recorded on file. (This was a previous recommendation) The Home’s new risk assessment format should be reviewed to make it easier for staff to recall the salient points. Consideration should be given to making one of the three bedrooms more comfortable and personalised. At least 50 of the care staff should achieve an NVQ in Care at level 2. (This was a previous requirement) Monthly independent audit visits to the Home, on behalf of the Registered Provider, should be made consistently. Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Henley Way (26) DS0000020012.V328945.R01.S.doc Version 5.2 Page 24 - 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!