Inspection on 10/08/05 for 287 Dyke Road

This inspection was carried out on 10th August 2005.

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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

287 Dyke Road 03/09/08

287 Dyke Road 19/01/08

287 Dyke Road 23/07/07

287 Dyke Road 15/06/06

287 Dyke Road 14/02/06

287 Dyke Road 11/01/05

287 Dyke Road 27/07/04

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

CARE HOME ADULTS 18-65 287 Dyke Road 287 Dyke Road Hove East Sussex BN3 6PD Lead Inspector Jennie Williams Announced 10 August 2005 09:30 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 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 Stationary 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. 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 287 Dyke Road Address 287 Dyke Road Hove East Sussex BN3 6PD 01273 566804 01273 509582 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care Management Group Vacant Care Home 8 Category(ies) of Learning disability (LD) 8 registration, with number of places 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 That service users are aged between eighteen (18) and sixty-five (65). 2 That service users have a learning disability. 3 That the maximum number of service users is eight (8). Date of last inspection 11 January 2005 Brief Description of the Service: 287 Dyke Road is one of many homes owned by Care Management Group (CMG). This company took over the running of the home in September 2004. It is registered to accommodate eight residents aged between eighteen and sixty five who have a learning disability. Residents at 287 Dyke Road have profound physical and learning disabilities. The home is located on a main road on the outskirts of Brighton. There is nearby access to some local amenities and access to public transport. There is limited parking available at the home, but parking is permitted on the street. The home has access to its own transport. Residents are provided with an opportunity to attend a day centre provided through the use of the organisations development centre. 287 Dyke Road has recently undergone major refurbishment work. All rooms are for single occupancy and are located over three floors. There is a passenger shaft lift available to allow access to all floors. It should be noted that although the home complies with the required communal area, there is no communal area that can accommodate all eight residents at any given time. This will restrict residents being able to participate in group activities within the home. 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 287 Dyke Road will be referred to as ‘residents’. This report is based on the findings of the specified inspection date. This announced inspection took place over seven and a half hours on the 10 August 2005. Staff files, some policies and procedures, records, care plans, individuals’ personal allowance and medication procedures were inspected. A tour of the home was provided. The environment and some individual rooms were spot-checked. Staff were spoken with throughout the inspection process. Due to the disability of the residents, the Inspector had limited communication contact with them. There were seven residents residing at the home on the day of the inspection. Five comment cards were received from health professionals, four received from relatives/visitors and one comment card from a resident. There is currently no registered manager at the home. A manager from a nearby CMG home is acting manager at 287 Dyke Road until a new manager is recruited. This manager, who is familiar with the staff and residents, facilitated the inspection. What the service does well: What has improved since the last inspection? What they could do better: There are minor shortfalls in some of the documentation at the home. Documentation needs to be improved to evidence that what is actually done 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 6 can be evidenced when tracking information. Some policies and procedures need to be amended to provide clear information for staff. 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. 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 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 standard(s) 1, 2, 3 & 4 The home has information available to prospective residents and their representatives to make an informed decision if the home is suitable for their needs. All prospective residents are assessed prior to moving into the home. EVIDENCE: The Statement of Purpose and Service User Guide were not inspected on this occasion. It was noted that these documents need amending to reflect the changes in staffing levels and to clearly identify that there is no communal area large enough for all residents to participate in group activities within the home. These documents have been amended to reflect the changes in the recent building works. These documents incorporate the use of pictures and symbols. All residents currently residing at the home have been admitted from other homes within CMG. The organisation has a central assessment team based in Wimbledon who undertake the initial assessment of prospective residents. The acting manager confirmed that the home will be involved in the assessment process and will make the final decision on admitting a resident. Copies of previous care plans/social services assessments are taken when available. Management will also obtain information from other health professionals, if applicable. 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 9 The home has good support systems in place through use of the organisations specialist health professionals eg. physiotherapist, speech and language therapists. Prospective residents/representatives are encouraged to visit the home prior to moving in. Due to the disability of the residents, admissions are generally well planned and the home will not take any emergency referrals or short-term admissions. On discussion with staff at the home, there are concerns that one resident is not appropriately placed within this home. This resident is more physically active than the other residents. Staff confirmed that this resident is unable to be placed out of their wheelchair with other residents unless staff are present. The home must ensure that the needs of this resident is kept under review and ensure their placement is in the best interest of all working and residing at the home. 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 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 standard(s) 6, 7, 8, 9 & 10 Residents’ needs are generally being met by the information contained in the care plans. Due to the profound disabilities of the residents, limited risk taking can be initiated. EVIDENCE: The home has detailed care plans, titled ‘all about me’. These are developed and reviewed with input from relatives and residents, wherever applicable. The use of photos was evident throughout the ‘all about me’. It was confirmed that ‘all about me’ were being reviewed every three months. There was no evidence that all sections of the ‘all about me’ were being reviewed. The home must ensure and provide evidence that all sections within the ‘all about me’ are reviewed every six months or earlier if the needs of an individual changes. Due to some residents being admitted from other homes, care plan formats vary between the residents. It was confirmed that staff are in the process of standardising all care plans. All residents have daily diaries that are kept with the individual to record daily activities and any changes in the needs of the individual. Keeping these diaries with the individual encourages good communication between the home care staff and the day centre staff and promotes continuity of care. 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 11 Residents have complex needs and communication is limited. Staff working at the home are able to interpret an individuals’ subtle level of communication and will include residents in the daily routines of the home wherever possible. Decision-making is limited for an individual. Residents require supervision in all activities they participate in, so taking risks are very limited. Some risk assessments were not dated or signed. It was noted that there were forms located in an individuals’ file that were no longer in use. It was discussed with the acting manager the importance that all documentation used to record care reflects actual practice. There are stretching and movement therapy programmes in place, but there were no records to evidence that the programme was being followed. It was discussed with the acting manager that the physiotherapists’ are encouraged to keep an individuals’ physiotherapy programme folder updated. Personal information is kept confidentially at the home. 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 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 standard(s) 11, 12, 13, 14, 15, 16 & 17. Residents are provided with opportunities for personal development and to be involved in the local community. Visitors are welcomed at the home. EVIDENCE: Residents are provided with a range of activities they are able to participate in. The development centre provided by the organisation provides opportunities for residents to engage in informative and creative activities should they wish. Two residents attend schooling. Due to the disability of the individuals’, no one is capable of being involved in employment. The Inspector was informed that there are three mini buses within CMG that is shared between five homes. It was confirmed that additional buses have been purchased. Staff informed the Inspector that residents are on occasion restricted in going out due to a bus or driver not being available. This has not been reflected as a requirement as it was confirmed that steps are being taken to address this shortfall. 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 13 Risk assessments must be undertaken for travelling in the bus and identify the number of staff required to assist an individual. The driver, who may also be a carer, must not be included in these numbers whilst they are driving the bus. Residents are encouraged to maintain contact with the local community and friends/relatives. Some residents have mobile phones and the staff will often text family members to keep them informed about an individuals activities etc. The home was currently implementing a summer programme for the residents. All residents have a daily routine. These routines are flexible, but due to the complex needs of the individuals’, residents respond better when there is a familiar routine in place. It was confirmed that residents are weighed on a monthly basis. There is only one resident able to take food orally. All other residents have clear feeding regimes. The Inspector observed a nasogastric feed and gastrostomy feed being undertaken. On observation, staff demonstrated that they were familiar with the feeding routines and necessary safety procedures. The setting on a pump corresponded with the information in the individuals’ ‘all about me’. There is restriction for the one resident on choosing their food to eat, due to the food being prepared at another CMG home and being transported to the home. It was confirmed that this individual chooses their drink, but not the meals. The home must look at providing in house cooking to promote the individuals’ choice and preference. 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 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 standard(s) 18, 19 & 20 Resident’s needs are being met by the skill mix of staff and support network of health professionals within the CMG organisation. Residents are safeguarded by the medication procedures within the home. EVIDENCE: The home does not provide nursing care. Due to the complex needs of residents, staff are required to have a clear understanding of all needs. Health needs are also met with the good support network throughout the organisation. It was observed that appropriate soft beanie toys were being used for one resident requiring pressure relief. This pressure relief was provided in a very tasteful and unobtrusive way. Four comment cards received from visiting health professionals demonstrated that they were satisfied with the overall care provided to residents within the home. One demonstrated that there was not always a senior member of staff to confer with. All comment cards demonstrated that any specialist advice given is incorporated into the residents ‘all about me’. There is no one capable of self-medicating at the home. There are policies and procedures in place to deal with all aspects of handling medication. MAR charts inspected demonstrated that there was one time that medication had 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 15 not been signed for at the time of administration or a reason provided why it may have been omitted. This was discussed with the deputy manager at the time. It was confirmed that all staff who administer medication have received training. There are photos of residents kept with the MAR charts. It was confirmed that the home has just commenced recording incoming and outgoing medication at the home. 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 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 standard(s) 22 & 23 Residents/representatives are provided with opportunities to air their views. Clear written policies will provide staff with clearer guidance on adult protection procedures. EVIDENCE: There is a complaints procedure available at the home. This needs amending to include the contact details of the local CSCI office. There is a pictorial complaints procedure that residents have access to which does include contact details. There have been no complaints made since the last inspection. Staff are familiar with the residents residing at the home and are aware of an individuals’ distinctive communication if they are unhappy about anything. There is a complaints book and a positive feedback book maintained at the home. The adult protection policy and procedure needs to clearly state that all allegations of abuse must be referred to social services, who are the lead agency. Information regarding the POVA list needs to be included in this policy. The acting manager confirmed that there is a training day arranged with an external agency for adult protection in September 2005. The whistle-blowing policy needs to be amended as it currently only focuses on abuse. It needs to be made clear that whistle blowing can relate to any practices within a home. It is recommended that the contact details of the local CSCI office be included in the whistle blowing policy. All residents have their own bank accounts. Residents’ monies spot-checked demonstrated that there are clear records kept of financial transactions. There is one person within CMG that is the appointee for residents. The Inspector was informed that it is proposed that the managing of the residents’ finances 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 17 were going to become the responsibility of the registered managers. This practice will not be supported by CSCI and other suitable measures will need to be implemented. 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 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 standard(s) 24, 28 & 30 Residents live in a homely environment but are unable to participate in group activities, as there is no one communal area that is large enough to accommodate eight residents at the one time. EVIDENCE: The home is located on a main road on the outskirts of Brighton. There is street parking available. Recent building works have been completed to increase the number of residents accommodated from three to eight. All rooms are for single occupancy and are located over three floors. There is a passenger shaft lift available to allow access to all areas of the home. Each floor has an assisted bathroom that meets the needs of the residents. On arrival at the home the Inspector went to the lounge room. There were four residents present in the lounge and it was obvious that no other resident would be comfortably accommodated in the lounge. It was confirmed that four residents are generally in the lounge, and three in the kitchen area. This will become crowded when an additional resident is admitted. All residents are wheelchair dependent. Staff informed the Inspector that group activities used to be undertaken. This is now limited due to no communal area being able to accommodate eight 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 19 residents at the one time. Staff confirmed that they were not consulted with the plans for the building work and are disappointed that group activities are no longer possible. Residents now participate in small activity groups in one of the larger bedrooms. Rooms spot-checked were seen to be personalised to reflect the individuals’ choice and character. The environment was not fully inspected on this occasion as the environment was inspected during the variation of registration. There is a ramp at the rear of the building to allow access to the rear garden. The home was clean and free from offensive odours on the day of the inspection. Staff expressed the concern that the call bell systems’ control panel is located on the ground floor. This can pose as a problem when staff may be upstairs and unclear who may be requiring assistance. This has already been identified as a shortfall and action will be taken to address this. This has not been reflected as a requirement. 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34 & 35 Residents’ needs are at risk of not being met due to insufficient staffing levels. Robust recruitment procedures must be followed to safeguard residents. EVIDENCE: Staff spoken with were happy working at the home and stated that there are opportunities to attend training sessions. Staff spoken with felt that there were not always sufficient staff on duty. The rota provided to the Inspector demonstrated that there were different numbers of staff on duty on different days. Staff informed that Inspector that due to staff shortages on some days, this imposed limitations for the residents to be able to be taken out. Two comment cards from visitors/relatives demonstrated that in their opinion there are not always sufficient numbers of staff on duty. It was confirmed that an additional six staff members have been recruited and are currently waiting for all appropriate checks to be returned. Management must ensure the needs of the residents are kept under review and ensure sufficient staff are on duty at all times to meet the assessed needs. There were some minor shortfalls noted in the staff files inspected. Management must ensure that a full employment history is obtained from all employees and ensure an explanation is provided for any gaps in employment. All staff files must comply with Schedule 2. A letter is received by the head office of the organisation stating that a CRB check has been undertaken. It is 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 21 recommended that this letter provides information to the manager if it was clear or not and that a POVA check has been undertaken. It is recommended that information regarding a prospective employees’ mental health status be expanded. It was confirmed that there is a copy of the GSCC Code of Conduct and Practice at the home. All staff must receive their own copy. A recent recruited staff member stated that they had not received a copy. 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 40 & 42 Residents and staff benefit from clear leadership within the home. Residents are safe guarded by the systems in place to monitor the health, safety and welfare of residents. EVIDENCE: There is currently no registered manager at the home. A registered manager from a CMG children’s’ home is acting as manager until a manager is recruited. There are clear lines of accountability within the home and with external management. Staff spoken with were complimentary about management at the home and found them approachable. A new key worker system has been implemented and there are clear roles and responsibilities within the home. CMG head office send out their own quality assurance documentation to residents families/representatives/health professionals on an annual basis and provides the home with feedback. 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 23 Not all policies and procedures were inspected. Any shortfalls in policies and procedures have been highlighted in the relevant sections of the report. The home receives policies and procedures from the head office of CMG. It is recommended that a quick reference guide be implemented so staff can quickly access the relevant policy they require. The pre inspection questionnaire demonstrates that all relevant health and safety checks are undertaken. All relevant certificates related to the recent building works were not inspected, as these would have been seen by the Inspector dealing with the variation of registration. 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 2 3 x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x 2 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score 3 x 2 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 287 Dyke Road Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 2 x 3 x H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 25 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. 1. Standard YA1 Regulation 4&5 Requirement That the Statement of Purpose and Service User Guide be amended to reflect changes in staffing levels and clearly identify that there is no communal area large enough for all service users to participate in group activities. To ensure that service users admitted have all their needs met. That evidence be provided that care plans are reveiwed at least every six months or earlier if the needs of an individual change. That evidence be recorded to demonstrate individual care plans are adhered to. That all risk assessments are dated and signed. That risk assessments are undertaken for travelling in the bus and identify the number of staff required to accompany an individual. The driver must not be included in these numbers. That the current system for the provision of meals be assessed in relation to service users and the homes level of choice and diversity. Timescale for action 31.10.05 2. 3. YA3 YA6 14 15 30.09.05 15.10.05 4. 5. 6. YA6 YA9 YA14 15 13.4 13.4(b&c) 30.09.05 30.09.05 30.09.05 7. YA17 16.2(h&i) 15.10.05 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 26 8. YA20 13.2 9. 10. YA22 YA23 22.7(a) 13.6 11. YA23 Appendix 2 20 12. YA23 13. YA33 18 14. 15. YA34 19 Schedule 2 That medication is signed for at the time of administration or reasons provided why it was ommited. That the complaints policy includes the contact details of the CSCI office. That the adult protection policy clearly states that all allegations of abuse must be referred to social services. Information about the POVA list needs to be included. That the whistle blowing policy is amended to state that it refers to any practice in the home and not just abuse issues. That the proposals to have managers as an appointee for service users is not implemented. That the dependency level of service users and staffing numbers be kept under review and adjusted accordingly. That staff files comply with Schedule 2. 30.08.05 15.10.05 15.10.05 15.10.05 31.08.05 15.09.05 30.09.05 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. Refer to Standard YA23 YA31 YA34 YA34 Good Practice Recommendations That the contact details of the local CSCI office is included in the whistle blowing policy. That all employees are provided with their own copy of the GSCC code of conduct and practice. That information regarding a prospective employees mental health status be expanded. That clearer information is provided to the manager regarding the suitably of POVA and CRB checks. H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 27 287 Dyke Road 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection 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 287 Dyke Road H59 H10 S60762 287 Dyke Road V229738 100805 stage 4.doc Version 1.40 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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