Inspection on 13/07/05 for 290 Dyke Road

This inspection was carried out on 13th July 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 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

290 Dyke Road 11/09/08

290 Dyke Road 17/11/06

290 Dyke Road 22/02/06

290 Dyke Road 15/02/05

290 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 18-65 290 Dyke Road 290 Dyke Road Hove East Sussex BN1 5BA Lead Inspector Jennie Williams Announced 13 July 2005 9.30 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. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 290 Dyke Road Address 290 Dyke Road Brighton East Sussex BN1 5BA 01273 552069 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 Limited Ms Louise Davie Care Home 5 Category(ies) of LD (5) registration, with number of places 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the maximum number of service users to be accommodated is five (5). 2. That service users should be younger adults aged between eighteen (18) and sixty-five (65) years on admission. 3. That service users to be accommodated have a learning disability, or a physical disability Date of last inspection 15 February 2005 Brief Description of the Service: 290 Dyke Road is one of many homes owned by Care Management Group Ltd (CMG). This company took over the running of the home in November 2004. 290 Dyke Road is registered to provide accommodation for five residents with learning disabilities. Residents at 290 Dyke Road have profound learning and physical disabilities. The home is a converted bungalow. Three rooms are for single occupancy and there is one shared room, currently being used by one resident. There is no managers office nor facilities for staff. There are building works proposed to provide all rooms for single occupancy and to provide an office for the manager and staff to use. Residents will be moved into other accommodation whilst the building work is completed. 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 no 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. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 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 290 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 four hours on the 13 July 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 spotchecked. The pre inspection questionnaire was sampled and the Inspector received one comment card from a GP. Two residents were returned briefly to the home for the Inspector to meet. Residents are usually at the development centre during weekdays. Due to the disability of the residents, the Inspector had limited communication contact with them. There were limited staff on site to speak to and the Inspector only briefly observed interaction between staff and residents. There were four 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: There are minor shortfalls in some of the documentation at the home. The main concerns are around limited space, which should be addressed within the proposed building works. Files are kept in the lounge room, which does not 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 6 promote a homely atmosphere. Outstanding requirements from the last inspection report relate to the environment. 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. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.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 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.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) 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 was provided to CSCI when Care Management Group Ltd took over the ownership of the home. These documents will need updating to reflect the changes in staff and the changes occurring with the proposed building works. 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. There have been no new admissions at this home. The manager informed the Inspector that she has been assured by the company that she will be involved in the assessment procedure. It was reiterated to the manager the importance of her having the final say on whether an individual is to be admitted or not. It was noted that a completed pre assessment form was not signed nor dated. There were no copies of social service assessments available at the home. The home does ensure that annual social service reviews are completed. It is recommended that the home obtain a copy of other care plans/assessments 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 9 that may have been undertaken by other health professionals prior to admission. 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. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.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, 7, 8, 9 & 10 Residents’ needs are being met by the comprehensive information contained in the care plans. Due to the profound disabilities of the residents, limited risk taking can be initiated. EVIDENCE: The home has comprehensive care plans titled ‘all about me’. These are developed and reviewed with input from relatives, if applicable. Residents are involved in the process but are unable to comprehend a lot of the information. The ‘all about me’ are very detailed and include photos of the residents preferred position. All residents have daily diaries that are kept with the individual. None of these were available to read on the day of the inspection. It was confirmed that the daily routine and any changes in the individuals’ health is recorded in these diaries. Keeping these diaries with the individual encourages good communication between the home care staff and the day centre staff and promotes continuity of care. It was confirmed that care plans are reviewed every three months. There was no evidence to support this. Care plans must be reviewed at least six monthly or earlier if the needs of an individual change. The manager has recently introduced a key worker system. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 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. Decisions/views will be sought from family members/representatives, if applicable. Residents require supervision in all activities they participate in, so taking risks are very limited. There are suitable risk assessments in place to safeguard residents and staff in the activities of daily living. Personal information is kept confidentially at the home. This will be promoted further when an office is provided. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.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, 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. On the day of the inspection all residents were out for the day. The development centre provided by the organisation provides opportunities for residents to engage in informative and creative activities should they wish. Due to the disability of the individuals’, no one is capable of being involved in employment. The home has its own bus and there is a full time driver available. Risk assessments must be undertaken for travelling in the bus and identify the number of staff required to assist an individual. The driver, who is also a carer, must not be included in these numbers whilst they are driving the bus. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 13 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. Visitors are welcomed at the home. Residents may see visitors in their own rooms if they wish. There is a visitor’s book kept at the entrance of the home that all people must sign when entering and leaving the home. Residents are encouraged to be involved in the local community. It was confirmed that residents are weighed on a monthly basis. The variety and amount of food being eaten by residents could not be assessed as daily diaries were with the individuals. Meals are transported to 290 Dyke Road that have already been prepared by another CMG establishment. This practice has been discussed at previous inspections. Once the building works have been completed, it was confirmed that the preparation and cooking of meals will occur in-house. The timescale made at the last inspection will not be met. A new timescale has been set. It was confirmed that Environmental Health visited the premise in January 2005 and were happy with the current procedures in place. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.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, 20 & 21 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: Throughout the ‘all about me’ there are clear instructions on the preferred way an individual receives personal support. Clear photos on the preferred position an individual should be placed when in bed etc support this. All residents require full personal care due to the complex needs. 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. A comment card from a GP demonstrated that there were no concerns around the care being provided at the home. 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 medication was being signed for at the time of administration. All staff who administer medication has been trained and assessed as being competent. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 15 The manager confirmed that she wrote to families approximately three months ago regarding the wishes following death as recommended at the last inspection. One response has been received to date. The manager must ensure information is continued to be sought. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 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. The recording of an individuals’ monies needs to be improved. 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. There have been no complaints made since the last inspection. Due to the residents having limited verbal communication, views are often sought through parents. Staff are familiar with the residents residing at the home and are aware of an individuals’ distinctive communication if they are unhappy about anything. 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. It was confirmed that the home has requested a copy of the Brighton and Hove East Sussex Multi-Agency Guidelines for the Protection of Vulnerable Adults to have on site. 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 is included in the whistle blowing policy. Individuals monies spot-checked demonstrated that the system for recording could be improved. The Inspector needed to add receipts etc to ascertain the amount an individual had. Shortfalls were discussed with the manager and 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 17 someone from the local accounts office. There is one person that acts as an appointee for all four residents. A clear running balance of each individual’s monies must be maintained. Receipts are kept of any financial transactions. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 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 & 25 Residents will benefit from a more homely environment when the building works are completed. There is limited space available at the home to comfortably accommodate residents and staff. EVIDENCE: The home is located on a main road on the outskirts of Brighton. There is street parking available. There is one double room at the home. All rooms are currently being used for single occupancy. There is still a wheelchair user residing in a room that is under the NMS recommendations. This remains an outstanding requirement. The environment was only spot-checked as there are plans for building works to commence at the beginning of August. These building works will ensure that all rooms comply with current standards and additional communal space will be provided. An office will also be provided for the manager. Rooms spot-checked were seen to be personalised to reflect the individuals’ choice and character. There are risk assessments in place regarding the delivery of hot water. The home proposes to install thermostatic controls at hot water tap outlets at the time of the building works being undertaken, as required at the last inspection. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 & 36 Residents’ needs are currently being met with the number and skill mix of staff on duty. There has been no progress on staff working towards NVQ level 2 or equivalent qualifications. EVIDENCE: It was confirmed that no one has commenced NVQ level 2 training. The manager confirmed that this is beyond her control and is organised by the head office of CMG. This previous recommendation has now been made a requirement. 50 ratio of staff must be NVQ level 2 or equivalent by 31 December 2005. The home must provide evidence that there is work commencing towards achieving this target. There was evidence that staff receive training relevant to their roles. It was confirmed that there are generally three members of staff on duty in the morning. There is one staff member on duty at night and a sleeping night duty person nearby to provide additional support when required. The company must reassess the suitably and safety for the current strategies and ensure risk assessments are in place. A resident may require rectal medication if a seizure occurs. This is usually administered if the seizure lasts longer than four minutes. The manager/organisation must assess the feasibility of this sleep in 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 20 member of staff being able to reach the home and provide assistance within four minutes. Staff briefly spoken with were complimentary about management and were happy working at the home. There were some shortfalls in staff files that was discussed with the manager at the inspection. 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 recommended that this letter provides information to the manager if it was clear or not and that a POVA check has been undertaken. The home had recently recruited a new member of staff for night duties. This person was under 21. The Inspector informed the manager that no one under the age of 21 can be left in charge of the home. It was confirmed that staff now receive regular supervision as recommended at the last inspection. The opportunity for supervision will be promoted better when the manager is supplied with an office. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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, 42 & 43 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: It was confirmed that CMG are arranging training to ensure managers are provided with opportunities to achieve the required qualifications. The Registered Manager Award should be completed by the end of the year and NVQ level 4 in care will be commenced next year. The manager is registered with CSCI and has relevant experience to manage the home. Staff spoken with found management approachable. CMG head office send out their own quality assurance documentation to residents families/representatives. It was confirmed that this procedure now includes the views of other health care professional. Head office provides the home with feedback. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 22 CSCI received one comment card back from a GP. This demonstrated that the GP had no concerns regarding practices at the home and that staff demonstrate a clear understanding of the care needs of the residents. Any specialist advice provided is incorporated into the care plans. Not all policies and procedures were inspected. Any shortfalls in policies and procedures have been highlighted in the relevant section 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. Documents inspected demonstrated that all accident/incident forms must be fully completed. Fire testing records demonstrated that problems identified are being recorded, but no mention of where the problem is. This was discussed with the manager on the day. It was confirmed that there may not be a trained first aider on every shift at the home, but there would be one within all CMG homes that are located within the same area. The home must work towards ensuring there is a qualified first aider on duty at all times. Any shortfalls noted in health and safety have been identified in the relevant sections of the report. The manager needs to obtain a copy of the recent insurance certificate. The one being displayed on the day of the inspection had expired. It was confirmed that the insurance has been updated. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 3 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 2 1 x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score x 2 2 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 290 Dyke Road Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 2 3 H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4&5 Requirement That the Statement of Purpose and Service User guide are updated following completion of building works. That a copy of this amended document is forwarded to CSCI. That completed pre assessment forms are dated and signed. That evidence be provided that care plans are reveiwed at least every six months or earlier if the needs of an individual change. 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. (Outstanding from previous inspection, see content of report) 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 Timescale for action 30.09.05 2. 3. YA2 YA6 14.1 15 31.08.05 31.08.05 4. YA14 13.4(b&c) 31.08.05 5. YA17 16.2(h&i) 30.09.05 6. 7. YA22 YA23 22.7(a) 13.6 30.09.05 30.09.05 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 25 8. YA23 Appendix 2 20 13.4(a) 9. 10. YA23 YA24 11. YA25 23.2 (e) 12. YA32 18 13. YA33 18 14. 15. 16. YA34 YA42 YA42 19 Schedule 2 Schedule 4 (12) Schedule 4 (14) 13.4 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 a clear running balance of each individuals’ monies be maintained. That all hot water outlets have indivdiual thermostatic valves fitted to ensure hot water temperature is regulated within acceptable limits. (Outstanding from last two inspections, see content of report) That single rooms in current use accommodating wheelchair users have at least 12 sq.m of useable space. (Outstanding from previous two inspections) That the home commences working towards the 50 ratio of care staff with NVQ level 2 or equivalent qualifications. (This outstanding recommendation has now been made a requirement) That an assessment of the suitably and safety for the current strategies regarding night cover be undertaken and ensure risk assessments are in place. That staff files comply with Schedule 2. That all accident/incident forms are fully completed. That the fire testing records show where the problem has been identified and not just what the problem is. That there is a qualified first aider on duty at all times. 30.09.05 31.08.05 30.09.05 30.09.05 31.12.05 31.08.05 30.09.05 31.08.05 31.08.05 17. YA42 30.09.05 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard YA2 YA21 YA23 YA33 YA34 YA40 YA43 Good Practice Recommendations That the home obtains copies of other health care professional care plans/assessments wherever applicable. That the manager continues to obtain information regarding the wishes of an individual following death. That the contact details of the local CSCI office is included in the whistle blowing policy. That no one under the age of 21 is left in charge of the home. That clearer information is provided to the manager regarding the suitably of POVA and CRB checks. That a quick reference guide be provided for the policies and procedure manual. That the manager obtains a copy of the up to date insurance certificate. 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.doc Version 1.30 Page 27 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 290 Dyke Road H59- H10 S60764 290 Dyke Road V229653 130705 stage 4.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. 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