Inspection on 16/05/05 for 29, 31, 33 Kingsley Road

This inspection was carried out on 16th May 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 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

29, 31, 33 Kingsley Road 05/12/07

29, 31, 33 Kingsley Road 30/08/06

29, 31, 33 Kingsley Road 12/10/05

29, 31, 33 Kingsley Road 07/01/05

29, 31, 33 Kingsley Road 27/05/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Kingsley Road (29,31,33) 29-33 Kingsley Road Chippenham Wiltshire SN14 0BF Lead Inspector Tim Goadby Unannounced 16th May 2005 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. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kingsley Road (29,31,33) Address 21-31 Kingsley Road Chippenham Wiltshire SN14 0BF 01249 445763 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) Royal Mencap Society Ms Caroline Powney Care Home 8 Category(ies) of LD Learning disability (4) registration, with number PD Physical disability (4) of places Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Not more than 4 service users with learning disability. 2. Not more than 4 service users with physical disability. Date of last inspection 7th January 2005 Brief Description of the Service: 29, 31 and 33 Kingsley Road provide care and accommodation for 8 adults, of either gender. Ages of the current group range from people in their 20s, to others in their 70s. The service is operated by Mencap, a national voluntary organisation in the learning disability field. Kingsley Road is run as one establishment. Numbers 29 and 33 each accommodate 2 people, who are able to be more independent. They do not need staff supervision at all times. But it can be accessed whenever necessary. The 4 people at number 31 need closer support. So this is where the staff team are based. This home includes the office, and sleep-in facility. The 3 houses are detached bungalows. They were purpose built in 1993, and are owned and maintained by Knightstone Housing Association. Kingsley Road is in a residential area of Chippenham, just 10 minutes walk from the centre. This market town offers a range of amenities. Rail and road links to the larger centres of Bath and Bristol are easily accessible. All service users have single bedrooms, with hand basins. There are no ensuite facilities. Each bungalow has a bathroom with a shower. There are also kitchens and a lounge. All the houses have their own area of garden. Kingsley Road (29,31,33) Version 1.30 Page 5 D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in May 2005. A total of 5 hours were spent in the home, in the late afternoon and early evening. Various telephone conversations and e-mail contact took place in the following days, with visiting professionals, and Mencap management. The following inspection methods have been used in the production of this report: indirect observation; sampling of records, with case tracking; discussion with service users, staff on duty, management, and other professionals; tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 6 There were a number of unmet requirements from the previous inspection. In addition, a significant number of new issues were identified. Support to the home’s newest service users was not fully evidenced. Records for these residents were deficient across a range of required areas. Guidelines for care and risk management were not in place. One service user’s welfare and safety was being put at risk. It was not clear that the home was yet able to meet all the assessed needs of this person. Resources such as equipment and staff training had not been put in place before admission. Suitable measures for moving and handling were not clearly established. Service users were at continuing risk from an unresolved issue about the effective operation of fire doors. Some records that are required to be available for inspection at all times were not. Staff levels are at a suitable minimum. But they are not clearly meeting all assessed needs of service users. Information about the type of service user that the home can support is not accurate, and needs addressing with the CSCI. 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. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 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 Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 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) 2, 3 & 4 Prospective service users have their needs assessed, and are able to undertake trial visits to the home. Service users’ needs were not all being met from the point of admission, placing them at risk of harm. Information about the home does not give an accurate reflection of who its service users are. EVIDENCE: The home’s newest service user had assessment information on file. This had been carried out by relevant professionals, before admission. Records showed that introductory visits had taken place, including overnight stays. A service user had moved from number 31 to number 33. A care manager for this individual confirmed her involvement with the process. The move had been assessed as suitable, and had been agreed by the service user concerned. But not all resources and facilities were in place to meet all needs of each service user. For the newest person, necessary changes to furniture and equipment had not yet been made, a month after admission. Staff training in Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 9 key issues, such as moving and handling, was taking place after admission. Care guidelines had not yet been devised. The home’s current registration categories and conditions do not accurately reflect the actual service user group. For instance, two people are aged over 65, which is not addressed. All service users have a learning disability, and some of them have associated physical disabilities. Current conditions only allow for people to have one of these classified areas of need. Following the previous inspection, the home agreed to make the necessary application to the CSCI to vary its existing registration. But the application had not been returned by the time of this inspection. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 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 & 9 Some service users had no suitable care plans or risk assessments, placing them at risk that their needs would not be met safely. EVIDENCE: The records of the home’s 2 most recent admissions were sampled. One moved to the home in late 2004; and another in April 2005. Neither had a suitable care plan in place. Other associated guidelines and documentation were also lacking. For instance, neither had any risk assessments in the home’s folder for these. Staff on duty were unable to give a consistent account of the support to be given to these individuals. Information was available about both service users. There was a lot of assessment and life history material, gathered before admission, or brought with the person from a previous home. The home’s ongoing records, and minutes of staff meetings, mentioned various relevant issues. But none of this had been developed into clear current guidelines for support. This left the arrangements for care undefined. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 11 For instance, there was an unspecific reference to possible behavioural management needs for one service user. The suggested approach was also not set out objectively. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 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) 12, 13, 14, 15 & 17 Service users have regular opportunities for appropriate activities, both at home and elsewhere. Service users are able to maintain and develop key relationships with family and friends. Service users are provided with appropriate meals. EVIDENCE: Service users regularly access opportunities outside the home. This includes employment, education, occupation and leisure. At this inspection, 2 people were away on holiday in Spain, supported by staff. Other service users confirmed they had holidays planned for later in the year. All service users had been out on the day of the inspection. They had attended various day centres or colleges. They spoke about the activities they undertake at these facilities. People appeared to enjoy these. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 13 A new admission had been to visit a local centre, to agree the sessions they would like to attend. Later in the afternoon, one person was supported by staff to go and withdraw money from their account at a local bank. Service users spoke about their family and friends. It was clear that they regularly have visitors, or go to stay with people. The evening meal at number 31 was prepared by staff on duty. The household dined together, except for one service user, whose preference was to eat in the lounge. At number 33, service users prepared their own meal, with some monitoring and supervision from staff. In both houses, people were consulted about what they would like to eat. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 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 Some service users did not have appropriate guidance in place to ensure effective personal care and health support. This placed them at risk of harm. EVIDENCE: Sampled care records lacked evidence of guidelines on key topics, such as how to deliver personal support, with particular reference to moving and handling. Some practices described by staff, and a service user, did not appear suitable or safe. Records showed evidence of input to address physical health needs. But not all relevant details could be found. Specific guidance had not been developed on key issues, such as diet. There was a record of discussion of such topics in staff meetings. But staff on duty were unable to give full information on these areas when questioned. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Appropriate procedures were in place to protect service users. EVIDENCE: Mencap’s organisational complaints arrangements are appropriate. Information is clearly displayed within the service. It includes symbols and photographs, to help make it more accessible to service users. Complaints records were not available at inspection. Please refer to the ‘Conduct and Management’ section of this report for further consideration of this issue. There is a full awareness of local procedures for the protection of vulnerable adults. When necessary, issues have been referred to this. The CSCI has also been notified of relevant matters. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 & 30 A service user was placed at risk of harm by a lack of suitable equipment, and the presence of unnecessary additional environmental hazards. Service users live in a comfortable and homely setting, that would benefit from continuing redecoration. Not all equipment is maintained to work effectively and safely. Service users live in a clean and hygienic environment. EVIDENCE: The newest service user’s bedroom was not suitable to safely meet their needs. The bed was too low for them to get in and out of comfortably. Both the service user, and staff on duty, confirmed this. The techniques described for assisting the person were not suitable or safe. No written guidance was available to confirm how the person was being supported. Other professionals involved with the placement stated that the need for the bed to be raised had been highlighted before admission. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 17 Bathrooms and toilets have various adaptations fitted to aid less mobile people, and wheelchair users. These include a fixed hoist for getting people in and out of the bath, wall bars, and doors that can be opened automatically. But the newest service user’s bedroom had no such adaptations. Also, a significant portion of available floor space had been lost, due to having to place a new chest of drawers in the middle of the room. It was planned to sort this out shortly. Repair and redecoration had taken place, was ongoing, or was planned, in a number of areas. The residents of number 29 were away on holiday, and the property’s lounge was being completely redone during their absence. The same home had had new flooring fitted in the bathroom. This needed some further work, as the seal was not yet secure. The utility room in number 31, where previously wall surfaces had required attention, had been made good. The corridor was due to be redecorated, and a wallpaper border had been removed in readiness for this. Large cracks in the wall of the lounge in number 33 had been filled, but not yet repainted. The bathroom floor in this property had also been renewed. Tumble driers in numbers 31 and 33 had not been working effectively for some time. On the day of the inspection, number 31’s was in operation, but making a high pitched squealing noise that was of nuisance value, and may have indicated a fault. The one in number 33 was demonstrated by service users to be even noisier. Staff agreed that this appeared unsafe, and took immediate steps to put it out of use. All 3 bungalows were seen to be clean and hygienic to a reasonable standard. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 18 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) 33 Staff cover is maintained at levels appropriate to meet the minimum needs of service users. The ability of the staff team to effectively support all service users at all times is limited on occasions, due to the increased dependency of some individuals. This may place others at risk. Staffing levels need further review, to ensure that they address all assessed needs of service users. EVIDENCE: 3 staff were on duty on the day of the inspection. One was a person who had been in post for 2 months; another was a relief worker, who had previously worked full-time at Kingsley Road; and the third was a new starter, on her first day. The new staff member explained that her first 2 weeks of shifts involved her ‘shadowing’ other staff. She was due to work at all the various times of day, to get used to the routines, as well as getting to know all the service users and staff. Only after this period would she start working as a full member of the care team. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 19 2 staff, including the registered manager, were away supporting a service user holiday. The senior staff member had been on duty earlier in the day. She also phoned later, to check if there were any issues that staff needed support with. Staff reported that there had been a period of high turnover. The majority of the team were relatively new in post. Rotas for May 2005 showed a mix of full and part-time staff, totalling just under 8 whole time equivalent workers. The newest starter would be an addition to that figure. Staff did not know if there were still other vacant posts. Rotas showed that cover was maintained at a minimum of 2 staff per shift at all times. This included 1 waking and 1 sleeping person overnight. 3 staff were on duty during daytimes, whenever possible. Relief cover was needed on the majority of days. An example was seen of an intensive shift pattern for one worker. Working a mixture of day and night shifts, the person was rostered to cover 36 hours, plus a sleep-in, within 5 consecutive days. This included 2 waking nights. On both occasions, the person had also worked a small part of the preceding day. Staff confirmed that 2 to 1 support was required for some service users, when assisting with personal care. Therefore, when there are only 2 staff on duty, the availability of support to other service users can be restricted. A previous recommendation highlighted the benefits of reviewing staffing levels at Kingsley Road. The service appears to be developing support to people with physical needs, arising from health and mobility. Staffing levels must be appropriate to meet the assessed needs of service users. This issue therefore remains a significant one, and may become a requirement if key needs continue to be unmet. Staff on duty were observed to interact positively and appropriately with service users. Support was given when necessary. Respect was also given to people when they wished to have more privacy. This included withdrawing to allow service users to have private conversations with the inspector. Records indicated that staff meetings take place regularly. Issues regarding service users, and the home generally, had been discussed. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 20 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) 41 & 42 Service users’ best interests are not safeguarded by the home’s record keeping systems. Service users are placed at risk of harm by ongoing failure to resolve an important issue of fire safety. EVIDENCE: The quality and content of service users’ records was seriously deficient in the 2 cases sampled. Neither person had suitable care plans or risk assessments. Decisions about admission to the home, and transfer between houses, were not fully recorded. Nor were future proposals for care and support. Details could be given by relevant professionals, who confirmed that appropriate discussions had taken place. But there was little awareness from service users, or staff on duty, about these processes. Important events such as review meetings, or health tests, were mentioned in daily records, but then not followed up to make the outcome clear. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 21 Previously, detailed notes relating to service users were mainly contained within minutes of staff meetings. This meant that part of the care record for each individual was on the same document as information about other people. It was recommended that it would be better for these records to be kept separate. Steps had been taken in response to this. Examples were seen where notes of staff meetings contained less detail, and were cross referenced to the relevant individual records. But there were also still examples of key information appearing in staff meeting minutes, rather than individual records. For the second consecutive unannounced inspection, it was not possible to check complaints records, as they were not available. It was thought that no complaints had been received. But this could not be verified. Complaints records, along with other areas specified in regulations, are required to be available for inspection at all times. So there should be a system for this. It is recognised that such a system may need to contain certain boundaries, where particular documents contain sensitive information. There continued to be one outstanding health and safety issue. For over a year there have been recurring problems with some fire doors at number 31. When tested, various ones have failed to close fully when the alarm system was activated. Records showed that these defects were still being found consistently. The problem was logged as ‘Ongoing’. Records indicated that the issue was being pursued with the housing association, which owns and maintains the property. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 22 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 x 3 1 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 2 3 3 2 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kingsley Road (29,31,33) Score 2 2 x x Standard No 37 38 39 40 41 42 43 Score x x x x 2 2 x D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 23 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 YA3 Regulation 12(1); 14(1) Reg 12, National Care Standards Commissi on (Registrati on) Regulation s 2001 (as amended) 12(1); 15 Requirement The persons registered must be able to meet all assessed needs of service users before providing accommodation to them. The persons registered must ensure that registration categories accurately reflect the service user group provided for. (Timescale of 31/03/05 not met) COMMENT: The service had obtained the necessary application forms, but these had not yet been completed and returned. Continued failure to address this requirement by the appropriate timescale will lead to further enforcement action. The persons registered must develop an individual plan for each service user, describing the support to be provided by the home. (Timescale from 07/01/05 not met) COMMENT: Continued failure to address this requirement by the appropriate timescale will lead to further enforcement action. The persons registered must carry out risk assessments for all Timescale for action From 16/05/05. Application to be received by the CSCI not later than 17/06/05. 2. YA3 3. YA6 From 16/05/05. 4. YA9 12(1); 13(4); From 16/05/05. Page 24 Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 5. YA18 15; 17(1)(a), Schedule 3(3)(q) 12(1); 13(5); 15 12(1); 13(1); 15 6. YA19 topics relevant to each service user, and demonstrate that suitable management strategies are in place. The persons registered must ensure that the personal support needs of service users are clearly set out in their individual plans. The persons registered must ensure that procedures are in place to address the healthcare needs of all service users. (Timescale from 07/01/05 not met) COMMENT: Continued failure to address this requirement by the appropriate timescale will lead to further enforcement action. Service user bedrooms must have sufficient useable floor space to be able to safely meet their needs. All service users must be provided with furniture suitable to meet their needs. The persons registered must ensure the provision of adaptations and equipment necessary to meet the assessed needs of individual service users. The persons registered must undertake a review of staffing levels, to ensure that these are in line with increasing dependency levels of service users. A suitable plan must then be put in place for any actions identified. COMMENT: There was no evidence that any review had taken place in response to a recommendation of the previous inspection. Information was also unclear about how staffing levels met the needs of the newest admission. In view of its From 16/05/05. From 16/05/05. 7. YA25 13(4) & (5); 23(2)(f) 13(4) & (5); 16(2)(c) 13(4) & (5); 23(2)(n) 18(1)(a) From 16/05/05. From 16/05/05. From 16/05/05. 8. 9. YA26 YA29 10. YA33 Review and action plan to be completed not later than 31/08/05. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 25 11. YA41 17(1)(a), Schedule 3 17(2), Schedule 4(11); 17(3)(b) 12. YA41 increasing importance for the service, this issue has now become a requirement. All statutorily required service user records must be maintained, to an appropriate standard. Complaint records must be available for inspection by the CSCI at all times. COMMENT: These records were again unavailable, despite a recommendation from the previous inspection. This has now been made a requirement. All fire doors must be repaired to ensure effective operation, as soon as any problem is noted and recorded. (Timescale from 27/05/04 not met) COMMENT: This has been a long running problem, which needs resolution with the housing association that owns and maintains the property. Continued failure to address this requirement by the appropriate timescale will lead to further enforcement action. From 16/05/05. From 16/05/05. 13. YA42 13(4); 23(4)(c) (i) From 16/05/05. 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. Refer to Standard YA24 Good Practice Recommendations Attention should be given to areas of décor in all 3 bungalows which are in need of renewal. COMMENT: Some progress had been made. Work was taking place on the day of the inspection. Further redecoration will enhance the overall appearance of each house. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 26 2. 3. YA30 YA41 There should be prompt repair or replacement of faulty tumble driers, for both practical and safety considerations. Any information likely to form part of the overall record of care for an individual service user should be held separately from similar information about other individuals. COMMENT: Some steps had been taken in line with this recommendation. But examples were still seen of individual service user information recorded in general documents, such as staff meeting minutes. 4. Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 27 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire, SN15 2BB 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 Kingsley Road (29,31,33) D51_D01_S28374_KINGSLEYROAD_V227304_160505_Stage4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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