Inspection on 14/02/06 for 287 Dyke Road

This inspection was carried out on 14th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 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 10/08/05

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 Hove East Sussex BN3 6PD Lead Inspector Jennie Williams Unannounced Inspection 14th February 2006 10:00 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 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 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 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. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 287 Dyke Road Address Hove East Sussex BN3 6PD Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01273 566804 Care Management Group Limited Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That service users should be younger adults aged between eighteen (18) and sixty-five (65) years on admission. The maximum number of service users to be accommodated is eight (8). That service users to be accommodated have a learning disability, not falling within any other category. 10th August 2005 Date of last inspection Brief Description of the Service: 287 Dyke Road is one of many homes owned by Care Management Group (CMG). It is registered to accommodate eight residents aged between eighteen and sixty-five years on admission who have a learning disability. Residents at 287 Dyke Road have profound physical and learning disabilities, not falling within any other category. The home is located on a main road on the outskirts of Brighton. There is nearby access to some local amenities and 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. 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 restricts residents being able to participate in group activities within the home. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 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 unannounced inspection took place over eight hours on the 14 February 2006. Staff files, some policies and procedures, records, individuals’ personal allowance and medication procedures were inspected. The environment and some individual rooms were spot-checked. Staff and residents were spoken with throughout the inspection process. Due to the disability of the residents, the Inspector had limited communication with them. Care plans were not inspected on this occasion. In order that a balanced and thorough view of the home is obtained, this inspection report should be read in conjunction with the previous inspection report of 10 August 2005. There were eight residents residing at the home on the day of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The recruitment procedures are required to be more robust. New staff must undertake an induction programme. Some policies and procedures still require to be amended to provide clear guidance for staff. Action must be taken to address shortfalls identified that affect the health and safety of staff and residents. All confidential information must be stored securely. Medication prescribed for individuals must not be stored in communal areas. The home needs to ensure that a manager is employed and completes registration with the CSCI. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 6 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 DS0000060762.V267161.R01.S.doc Version 5.0 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 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 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: It was confirmed that the Statement of Purpose and Service User Guide has been amended as required at the last inspection. This document was not available at the home on the day. It is required that a copy of the amended documents are forwarded to CSCI and available at the home. These documents incorporate the use of pictures and symbols. The organisation has a central assessment team based in Wimbledon who undertake the initial assessment of prospective residents. The home is involved in the assessment process. Copies of previous care plans/social care assessments are taken when available. Information is obtained from other health professionals, if applicable. There have been no new admissions to the home since the last inspection. The home has good support systems in place through use of the organisation’s specialist health professionals eg. speech and language therapists. CMG is currently in the process of employing a new physiotherapist. Prospective residents/representatives are encouraged to visit the home prior to moving in. Due to the disability of the residents, admissions are generally well 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 9 planned and the home will not take any emergency referrals or short-term admissions. There were concerns raised at the last inspection by staff that one resident was inappropriately placed at this home, due to this individual being more physically active. It was confirmed that needs are being met and this individual is progressing well. Head office and the referral team within CMG have decided this resident will remain living at the home. Staff confirmed that the individual is developing well and appropriate to remain living at the home. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 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): 7, 8 & 10 Staff are provided with guidance on how to meet the assessed needs of individuals. Due to the profound disabilities of the residents, limited risk taking can be initiated. EVIDENCE: Care plans, called ‘all about me’, were not inspected on this occasion. The last inspection demonstrated that these contained detailed information. Some residents were admitted from other homes within the CMG organisation. Care plans remain on different formats. CMG are have developed a new Health Booklet that will include all relevant information about an individual. It was confirmed that they contain comprehensive information on an individuals’ health needs. Management have received training in the use of these new documents and information regarding an individual will be transferred to these new documents. Once this health booklet is completed, it was confirmed that all care plans will be updated onto one format. The acting manager confirmed that action has been taken and care plans are to be reviewed every three months. Additional forms have been developed and implemented to evidence that specialist needs identified in the care plan 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 11 are adhered to, as required from the last inspection. The importance of documentation is discussed at staff meetings and reiterated during supervision sessions. 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. A new daily diary sheet is going to be implemented with the new health action plans being implemented. New epileptic care plans have been developed. Residents have complex needs and verbal 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. Current information is stored and locked securely in the office when no one is available. There was confidential information found in a storage area. This information was not stored securely. It is required that all confidential information is stored securely. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 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): 11, 13, 14, 15, 16 & 17 Resident’s 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, ran by the organisation, provides opportunities for residents to engage in informative and creative activities should they wish. It was confirmed that there are four mini buses that are shared between five homes, the school and the development centre. This poses some restrictions for the home. It has been recognised that another bus is required to meet the needs of all the establishments having to share transport. It is recommended that priority is given to providing additional transport. Risk assessments for travelling in the mini bus has been implemented as required at the last inspection. CMG has an indoor swimming pool located at the rear of another CMG home. It was confirmed that this has not been useable for approximately six months. It is recommended that priority be given to making this facility useable again for residents. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 13 Visitors are welcomed at the home. There is a visitors book at the entrance of the home that all people must sign when entering and leaving. Residents are encouraged and supported to develop and maintain relationships with friends and family. 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. There is only one resident able to eat orally. All other residents have clear feeding programmes in place. Some feeding programmes have been altered with advice from relevant health professionals. This has been to the benefit of the individual. Cooking is now done at the home, as required from the last inspection. A menu is devised with the individual who is able to eat orally. Not all staff that prepare and cook meals have received food and hygiene training. This training is being arranged by head office of CMG. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Resident’s needs are being met by the numbers of staff on duty at all times. Residents are generally safeguarded by the medication procedures in place. EVIDENCE: The home does not provide nursing care. District nurses will visit the home when nursing needs are identified. There is one resident with a pressure sore. District nurses provide support and advice when required. Due to the complex needs of residents, staff are required to have a clear understanding of all needs. CMG is currently employing a new physiotherapist. It is anticipated that this person will commence work in April 2006. The previous physiotherapist gave a handover to the Care Co-ordinator who is addressing any outstanding needs/equipment required. Residents’ postural management programmes are still being undertaken. There is no one capable of self-medicating at the home. It was confirmed that there are policies and procedures in place to deal with all aspects of handling medication. MAR charts inspected demonstrated that medication is being singed for at the time of administration, as required at the last inspection. It is recommended that hand written MAR charts are signed by two staff who have undertaken medication training. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 15 There was medication prescribed for individuals stored in a communal bathroom. There was medication prescribed for an individual found in another residents’ room. This has not been reflected as a requirement as these issues were addressed on the day of the inspection. The acting manager confirmed that the care coordinator undertakes monthly medication audits. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 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. It remains an outstanding requirement that this policy 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 has been one complaint made directly to the home since the last inspection. This is currently ongoing. Staff are familiar with the residents residing at the home and are aware of an individuals’ distinctive communication if they are unhappy about anything. It remains an outstanding requirement that the Protection of Vulnerable Adults (POVA) 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. It was discussed with management at the home that steps be taken to amend this locally whilst awaiting for the head office of CMG to forward on an amended policy. Staff confirmed that they have received POVA training. There was one incident noted where a substantial amount of a resident’s money went missing. Records at the home demonstrated that this incident was not dealt with following correct POVA procedures. It was confirmed that the police had been contacted. This was not reported to CSCI under Regulation 37. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 17 It remains an outstanding requirement that 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. There is one person within CMG who is the designated appointee for residents’ finances. The home holds personal allowances securely at the home. Personal monies spot-checked demonstrated that there are suitable procedures in place for handling residents’ personal allowance. Receipts are kept for all financial transactions. Safety measures and regular checking of residents’ monies have been implemented following a recent incident at the home. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 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: 287 Dyke Road is one of many homes owned by Care Management Group (CMG). It is registered to accommodate eight residents aged between eighteen and sixty-five years who have a learning disability. The home is located on a main road on the outskirts of Brighton. There is nearby access to some local amenities and 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. 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. Hot water was found to being delivered up to around 48°C. It was made an Immediate Requirement that risk assessments are in place for hot water taps delivering water above 43°C, until pre set valves are in situ. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 19 Group activities are now limited due to no communal area being able to accommodate eight residents at the one time. Residents now participate in small activity groups in one of the larger bedrooms. At the last 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. No requirement had been made around this as it was confirmed action would be taken to address this shortfall. On the day of the inspection it was noted an intercom was broken and had previously been reported to be repaired. The home was awaiting for head office of CMG to address this. No action had been taken. It was made an Immediate Requirement that the intercom is working effectively and suitably placed to be heard by staff when working with residents. Rooms spot-checked were seen to be personalised to reflect the individuals’ choice and character. The environment was not fully inspected on this occasion. 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. It is recommended that domestic staff are provided with opportunities to undertake infection control training and other training relevant to their duties. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 Residents’ needs are being met with the numbers of staff working at the home. Residents would be protected and safeguarded better if the home implemented robust recruitment procedures. EVIDENCE: Staff spoken with confirmed that they have been provided with job descriptions and are clear on their roles and responsibilities. Staff confirmed that they are awaiting for their contracts/terms and conditions from head office. One new staff member spoken with stated that they had not received a copy of the GSCC code of conduct and practice. This remains an outstanding recommendation. The home needs to continue to work towards the required 50 ratio of NVQ level 2 or equivalent qualified staff on duty. There is one carer undertaking their NVQ level 3 studies. It was confirmed that five staff are commencing NVQ level 2 training. There is 21 care staff in total. There has been six new staff employed since the last inspection. The home is currently fully staffed. Staff spoken with felt that there were sufficient numbers of staff on duty to meet the assessed needs of residents. Staffing levels have been improved as required at the last inspection. It was confirmed that the only time there may be a shortfall of staff numbers is due to staff illness. Regular staff meetings take place. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 21 Staff files inspected demonstrated that there are major shortfalls in the recruitment procedures. There was no information available for one new staff member and lack of information available on two other new staff files inspected. A staff member was observed to be working unsupervised with only a POVA First check. Another new staff member had commenced employment prior to a CRB disclosure being applied for. The home has been made aware that CRB forms are not transportable between different places of work. Some references were obtained from friends, although the previous job for this carer was in the care field. Major shortfalls in the recruitment procedure were discussed on the day of the inspection. It was made an Immediate Requirement that all staff files comply with Schedule 2 and that steps must be implemented to supervise new staff until a complete enhanced CRB disclosure is received. Some new staff spoken with confirmed that they have not received any induction. New staff, some having been employed for three months, have not received suitable induction. Records inspected also demonstrated a major shortfall in the induction process. It is required that all new staff undertake suitable induction. This shortfall poses a risk to residents. The Inspector asked three new staff where the fire meeting point was and three different responses were given. Some staff confirmed they are receiving supervision, whilst other were not. Senior staff are responsible for supervision. The acting manager confirmed that staff undertaking supervision have not received training for this role. Staff providing supervision must be trained for this role. Head office of the CMG organisation arranges the training schedule and sends this to the home on a regular basis. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 Residents could be better protected if the identified management and health and safety issues were addressed. EVIDENCE: CMG is currently in the process of recruiting a manager. Concerns regarding management arrangements will be dealt with by CSCI outside of the inspection process. Staff spoken with felt that there was a good working team at the home. There is a commitment to equal opportunities at the home. Work is being done to update residents’ inventories of personal belongings following the Christmas period. There were concerns noted regarding health and safety issues. The call bell system was not working effectively, as highlighted in the environment section. Some fire doors were not closing securely. Ineffective fire doors had been noted during weekly fire testing and reported to be repaired. No action was taken over a period of time. An Immediate Requirement was made that fire 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 23 doors close effectively. One door was being held open by a curtain tie back. This was addressed on the day of the inspection. The home needs to continue to work towards ensuring there is always a qualified first aider on duty at all times. Windows were noted to be unrestricted. It is required that window restrictors be installed. This is to promote the security for staff and residents, working and residing at the home. Any other shortfalls in the health and safety have been highlighted in the relevant sections of the report. 287 Dyke Road is one of many homes within a growing organisation. The home has given no cause of concern regarding financial viability to date. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 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 3 3 X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 X 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X X 2 X 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 1 1 2 CONDUCT AND MANAGEMENT OF THE HOME 3 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 X X X X X 1 X DS0000060762.V267161.R01.S.doc Version 5.0 Page 25 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 YA1 Regulation 4&5 Requirement That a copy of the amended Statement of Purpose and Service User Guide is forwarded to CSCI and available at the home. That all confidential information is stored securely. That all staff preparing and cooking meals are provided with food and hygiene training. That the complaints policy includes the contact details of the CSCI office. (Timescale 15.10.05 not met) 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. (Timescale 15.10.05 not met) That the whistle blowing policy is amended to state that it refers to any practice in the home and not just abuse issues. (Timescale 15.10.05 not met) That the intercom is working effectively and suitably placed to be heard by staff when working with service users. (Immediate DS0000060762.V267161.R01.S.doc Timescale for action 31/03/06 2. 3. 4. YA10 YA17 YA22 17(1)(b) 18(1)(c) 22.7(a) 15/03/06 30/04/06 31/03/06 5. YA23 13.6 31/03/06 6. YA23 Appendix 2 31/03/06 7. YA29 16(2)(c) 24/02/06 287 Dyke Road Version 5.0 Page 26 Requirement) 8. YA34 19 Schedule 2 19 Schedule 2 18(1)(c) 18(2) 13(4) That staff files comply with Schedule 2. (Timescale 30.09.05 not met, Immediate Requirement)) That all staff working with a POVA First check are supervised until a full enhanced CRB check is returned. (Immediate Requirement) That all new staff undertake and complete a suitable induction programme. That staff providing supervision are trained in the supervisory role. That risk assessments are in place for hot water being delivered above 43° C. (Immediate Requirement) That pre set valves are placed at outlets delivering water above 43°C. That fire doors close effectively. (Immediate Requirement) That there is provision of a qualified first aider at all times. That windows are restricted. That the home complies with Regulation 37 reports. 24/02/06 9. YA34 14/02/06 10. 11. 12. YA35 YA36 YA42 31/03/06 15/04/06 15/02/06 13. 14. 15. 16. 17. YA42 YA42 YA42 YA42 YA42 13(4) 23(4) 13(4) 13(4) 37 15/03/06 24/02/06 15/04/06 30/04/06 15/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA14 YA14 YA20 Good Practice Recommendations That consideration is given to providing additional transport. That priority be given to making the swimming pool useable for service users. That hand written MAR charts are signed by two staff who have undertaken medication training. DS0000060762.V267161.R01.S.doc Version 5.0 Page 27 287 Dyke Road 4. 5. 6. 7. 8. YA23 YA30 YA31 YA32 YA34 That the contact details of the local CSCI office be included in the whistle blowing policy. (Outstanding recommendation) That domestic staff are provided with infection control training and other training relevant to their duties. That all employees are provided with their own copy of the GSCC code of conduct and practice. (Outstanding recommendation) That the home continues to work towards having 50 ratio of staff NVQ level 2 qualified. That information regarding a prospective employees mental health status be expanded. 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 287 Dyke Road DS0000060762.V267161.R01.S.doc Version 5.0 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. 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!