Inspection on 05/10/05 for 3-5 St Matthews Road

This inspection was carried out on 5th October 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3-5 St Matthews Road 04/03/08

3-5 St Matthews Road 03/05/06

3-5 St Matthews Road 20/04/05

3-5 St Matthews Road 07/09/04

3-5 St Matthews Road 05/04/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 3-5 St Matthews Road St Leonards on Sea East Sussex TN38 0TN Lead Inspector Caroline Johnson Announced Inspection 5th October 2005 09:30 3-5 St Matthews Road DS0000028056.V250590.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 3-5 St Matthews Road DS0000028056.V250590.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. 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 3-5 St Matthews Road Address St Leonards on Sea East Sussex TN38 0TN 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) 01424 445924 Sussex Autistic Community Trust (Care Services) Limited Mr Stewart John Cowley Care Home 9 Category(ies) of Learning disability (9) registration, with number of places 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That only service users with an autistic spectrum disorder may be admitted. That the maximum number of service users to be accommodated is 9 (nine). That service users are aged between 18 (eighteen) and 65 (sixty-five) years on admission. 20th April 2005 Date of last inspection Brief Description of the Service: 3-5 St Matthews Road is registered to accommodate nine adults with an autistic spectrum disorder. The home is one of four homes in East Sussex run by the Sussex Autistic Community Trust. The registered premises consists of two semi-detached houses arranged into three separate units. House no.3 has one unit accommodating five residents whilst house No.5 has two units, one for one resident and the second for three residents. Each unit is staffed separately, whilst a manager oversees the whole service. The home is situated a short walk from the Silverhill area of St Leonards on Sea, with its local amenities and shops. Bus services run close to the home. 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, the second in the year running form April 1 2005 to March 31 2006. The inspection lasted from 9.30am until 5.50pm. Time was spent with the manager and deputy manager going through various records and documentation. There was an opportunity to meet with one resident in private and another resident chose to have a member of staff present. In addition three other residents spoke briefly with the inspector over the course of the inspection. Four staff were also interviewed individually. A full tour of both houses was also undertaken. This report needs to be read in conjunction with the previous inspection report dated 20 April 2005. At that time the impact of one of the resident’s changed healthcare needs was evident in the home and this was causing a lot of stress for the other residents and the staff team. Since the last inspection there have been settled periods but also some unsettled periods. The home has worked hard to reduce the levels of stress. However, all measures taken can only work in the short-term and the home is working with Social Services to bring about change that will meet the needs of the individual concerned. What the service does well: What has improved since the last inspection? The home are gradually introducing a new format for care planning. The main improvement on the old system is that there is now space to include more information on residents’ progress with their individual goals. The home now uses a TEACCH programme (Treatment and education of autistic and related communication of handicapped children). This programme involves the use of symbols, widgets or words to aid communication and is being used to encourage residents to make a wider variety of choices and to participate more in the running of their home. A new bathroom has been installed in house 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 6 five. An alarm system has been installed in house three so that in an emergency situation they can now seek assistance from house five more easily. The system for recording residents’ finances has been revised and is now much clearer. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 3-5 St Matthews Road DS0000028056.V250590.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 3-5 St Matthews Road DS0000028056.V250590.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): 2,3 The home is able to meet the needs of all but one of the residents. This resident has been voicing their wish to move to alternative accommodation for some time. EVIDENCE: At the last inspection it was assessed that the home was meeting all but one of the residents’ needs. Prior to that inspection the home had been in discussion with Social Services regarding the future needs of the resident. However, following that inspection the resident became more settled for a period and prior to finalising the report it was agreed that the requirement made should be kept under review. Since then there have been further unsettled periods. Prior to this inspection a meeting was held to discuss the resident’s future needs and due to the complex needs of the resident further meetings will be held to decide on the best course of action. The resident continues to voice their request that alternative accommodation be found. 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,9 Care plans include detailed information for staff to follow in order to meet the needs of the residents. The new format for care planning, that is currently being introduced should build upon what is already in place. In particular it will allow for more detailed information to be recorded about progress made with identified goals. EVIDENCE: The format used for care planning has recently changed. Staff are still in the early stages of transferring over all relevant information into the new care plans. The new format once completed should allow for detailed information to be recorded and there is also space for staff to comment on the individual progress made by residents in meeting their goals. Daily records are kept in respect of each individual. A new format has also been devised for this purpose. As well as showing planned activities for each day there will also be a section showing the actual activities. In respect of the care plans seen, risk assessments had been reviewed and were up to date. As required at the last inspection, in relation to one resident, there was a risk assessment in place detailing the action to be taken should the resident have a seizure. 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 10 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): 11,12,13,14,17 With the exception of one resident, there is a programme of activities in place for everyone. Residents participate in varied and interesting activities. The use of the TEACCH programme will be invaluable in assisting residents to communicate their wishes and to be more involved in the running of their home. The revised arrangements in place for managing residents’ finances are working well although a recommendation has been made in relation to the storage of documentation. EVIDENCE: The majority of residents attend day centres through the week. A small number can travel independently to their centre. Some also attend college courses and one resident has a work experience placement. One of the residents advised that he has recently starting travelling independently to his day activities. Each of the residents has a timetable of the activities that they participate in. Timetables seen are varied and for some include activities such as aromatherapy, horse riding, swimming and trips to places of interest. 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 11 There are different arrangements in each of the units to aid communication with residents and these are based on the abilities and needs of each of the residents. The home uses a TEACCH (Treatment and education of autistic and related communication of handicapped children) programme, which involves the use of symbols, widgets or words to aid communication. The programme is used in everyday tasks such as planning meals, shopping for food and meal preparation. Menus seen showed that residents receive a varied and well balanced diet. The systems in place for supporting residents to manage their finances have been reviewed. A risk assessment is now carried out in respect of each individual resident. Records were seen in respect of one resident’s finances and these were in order. It was recommended that the home review their procedure for the storing of some documentation relating to residents finances. Some of the residents had recently returned from holidays. One trip had been to Devon and another to Spain. A staff member had produced calendars for 2006 showing a picture of each of the residents on the Devon holiday. One of the residents has decided that he would like to produce a newsletter giving details of his holiday. Staff will provide support to the resident so that this can be achieved. One of the residents advised the inspector that the day centre would be closed for one week for staff training. He and a few of the other residents have drawn up a plan of the activities that he and some of the other residents would like to participate in over the week. It was an action packed week with trips to theme parks, a zoo and to London. 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 12 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): 18,20 Staff observed in the course of their duties were courteous and friendly and treated the residents with respect and dignity. EVIDENCE: The arrangements in place for the storage and handling of medication were discussed with a staff member in house three. Storage facilities were seen and records of medication administered to residents were examined and were in order. All staff have received training on the medication in use in the home. 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 13 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 There is a detailed complaint procedure in place. The home responds quickly when complaints are made to them. Some of the complaints that have been made in recent months are founded but cannot be resolved completely in the short-term. The home is working towards ensuring that all staff receive training on adult protection and prevention of abuse. EVIDENCE: Within the last twelve months there were twenty-eight complaints recorded. However, records showed that complaints were significantly reduced in the last six months with no complaints at all in the last three months. Some of the complaints are ongoing and cannot be resolved in the short-term. The home’s adult protection procedure now includes information on what constitutes abuse. Half of the staff team have received training on POVA and arrangements are being made for those not yet trained to receive appropriate training. 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 14 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): 24,25,26,27,28,29,30 Overall accommodation in both homes is clean, comfortable and homely in design. There are some areas where redecoration or replacement of equipment is necessary. Accommodation in the top floor of house three is unacceptable and urgent work is required to improve the quality of the environment in terms of safety, ventilation and decor. EVIDENCE: House five Since the last inspection one of the rooms upstairs in house five, which had been an office has now become a bedroom and what was a bedroom has now become a bathroom. The new bathroom has a bath, a separate shower, toilet and washbasin. Bedrooms are personalised to reflect the individual personalities of the residents. The deputy manager advised that the carpet in the dining room is due to be cleaned, the fridge freezer is due to be replaced and the ceiling in the lounge will be repainted. In one of the bedrooms there was a strong odour. However, the bed and the flooring are due to be changed in the near future. On the ground floor there is a one bedroom flat to which there is a separate entrance. The accommodation is spacious and has been personalised. The manager advised that the flat is due to redecorated in the New Year. 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 15 However, the carpet in the lounge area is rucked in places and this poses a risk of tripping. There is a small patio area to the rear of the flat and a gate from this leading into a garden area. The garden area was tidy and well kept. House three There is a one-bedded unit on the top floor. This comprises a bedroom, lounge, kitchen and bathroom. All areas are in need of complete redecoration. The resident occupying this flat has complex needs. There are holes in a number of the walls that need to be re-plastered. As a short-term measure MDF has been fitted in places to prevent further damage. Windows are boarded preventing light/noise entering. The kitchen window is the only window not boarded. This is a velux window, which is opened very occasionally for short periods only. As a result the flat is poorly ventilated and dark. Furniture provided is minimal. The kitchen area is small and there are sloping ceilings. Staff advised that not all meals are cooked in this area. If it is considered that the risk of cooking in the kitchen area is too great then meals are prepared downstairs and taken to the flat. The washing machine in this kitchen is not in working order. In the bathroom there is a bolt lock on the door, which needs to be removed and replaced with a more suitable lock. The water pressure in the bath is low and the manager advised that the plumber was due to visit the following day to attend to this problem and also to adjust the hot water temperature. On the second floor there are bedrooms and a bathroom. On the ground floor there is a lounge, dining room, garden room and a kitchen. The manager advised that the lounge is due to be repainted next year. All areas seen were clean. As required at the last inspection a new alarm system has been installed in house three. This is also linked to house five so that should staff need assistance in an emergency situation they can do this quickly. In addition there is an alarm fitted outside the top floor unit so that staff can more easily provide support to the resident when needed. Records seen in respect of fire safety were generally in order. However, in respect of records in relation to fire drills, it was recommended that records also show the time of the drill and how long the drill took. In addition the evaluation of each drill should make reference to staff performance. 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 16 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): 32,33,34,35,36 A review of staffing levels in house three must be carried out. Staff in house five must also receive training on the management of residents in house three so that they can provide appropriate assistance if called in an emergency situation. Recruitment procedures have been thorough and staff receive a good induction to the home along with regular opportunities to receive training that is relevant to their position. EVIDENCE: There was some confusion over the staffing levels in house three. From discussion with a number of staff it would appear that in the main staffing levels are satisfactory. However there are times when two of the residents can present as very challenging and when these occasions arise this can mean that other residents receive less attention. Some of the residents go home to their parents at weekends. One member of staff stated that staff need to be very skilled and to know the residents well, as dealt with incorrectly this could lead to increased levels of challenging behaviour. At one point there used to be two carers on duty in each of the houses and in house three there was an extra member of staff working nine to five. The nine to five position is no longer used. Staff state that one of the resident’s receives one-to-one support. The confusion is whether the resident is actually funded to receive one-to-one. An application has been submitted to Social Services applying for extra funding to provide an additional member of staff for 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 17 four hours each day to support one of the residents. Staffing levels in house five were assessed as satisfactory. However, one of the staff in house five stated that should the emergency alarm in house three sound, a staff member from house five would be expected to attend to provide assistance. Staff in house five have not yet received training on how to deal with the residents in house three in a crisis situation. The manager agreed that such training could be provided. The manager advised that the need for waking night staff in house three is kept under continual review. At the time of inspection it was considered that this was not necessary. Recruitment records were seen in respect of one member of relief staff. Records showed that the home were thorough in carrying out appropriate checks. In addition the member of staff concerned had received regular supervision sessions. Staff spoken with during the inspection all stated that they received regular supervision sessions and that they found them very useful. They stated that they found the management team very supportive one member of staff stated that when they are presented with problems `they always have useful ideas’. Staff also stated that the `training opportunities are excellent’. The majority of staff are up to date with mandatory training and a large number of the staff team have received autism specific training. One of the staff stated that she was due to attend a course on epilepsy later in the week. One of the staff stated that they had received a very thorough induction for working on a one-to-one with one of the residents. They also stated that new staff working with this resident, need to shadow an experienced member of staff doing each of the activities that they participate in, prior to working with this resident on their own. The need for consistency is extremely important as if the pattern changes even slightly this can cause a huge amount of anxiety for the resident. The consistency has helped to significantly reduce the frequency of incidents. 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 18 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): 37,38,39,40,42 The manager is qualified and competent in his role. However, he needs to make arrangements to complete NVQ level four. The manager had made arrangements to address the problem identified with the hot water at three outlets. The home has sent questionnaires to the relatives of residents to seek their views of the care provided. They now need to extend this by seeking the views of the residents. The manager has been proactive in trying to arrange a meeting with Social Services and other professionals so that the wishes and accommodation needs of one of the residents could be discussed. The manager and deputy have revised the home’s policies and procedures document and these now need to be approved by the board of directors and made available to staff. EVIDENCE: The manager advised that he has completed half of the NVQ level four course. He still needs to complete the second half and he hopes to be able to register on an appropriate course in the coming months. He is a qualified nurse in 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 19 learning disabilities and has a number of years experience with this client group. Records seen in respect of the monitoring of hot water temperatures showed that at three outlets the water temperatures were well in excess of agreed safety limits. Hot water tested at one of these outlets showed a reading in excess of 70° C. The manger advised that the plumber had been notified and was due to visit the day following the inspection. There are no window restrictors on windows above ground floor. A risk assessment has been carried out in the past. However, it was recommended that this be reviewed to assess if there is a need to have restrictors fitted. As required at the last inspection of the home a questionnaire has been sent to the relatives of the residents to seek their views on the quality of care provided in the home. The manager advised that he would be collating the responses and sending this to all the relatives. He also agreed to send a copy to the Commission. A questionnaire has yet to be sent to the residents. As part of the inspection process comment cards were sent to relatives of residents and to the residents. Six responses were received from relatives. One relative stated that they had an occasion to make a complaint to the home but that the complaint had been resolved satisfactorily and the problem had not reoccurred again. Another relative stated that there was not always sufficient staff on duty. All other comments were positive. One relative stated that they were `very impressed with the commitment and imagination shown by the staff’. Seven comment cards were received from residents. Three of the seven residents required some support to complete the comment cards. Five of the seven responded positively to the questions, one stated that they would like to be more involved in the running of the home sometimes and one resident, stated that they were not happy in the home, didn’t feel well cared for, didn’t feel that staff treated them well and didn’t feel safe. The home are aware of this resident’s desire to move to alternative accommodation and are in discussion with Social Services regarding this. The resident concerned whilst happy for the inspector to see their current accommodation chose not to speak with the inspector. The home now sends copies of all incidents reports to the Commission. The manager advised that a number of new policies and procedures have been drawn up. They are currently in draft form and have been sent to the board of directors for approval. He hoped that they would be approved and available for staff to read in the near future. 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 20 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 x 2 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 3-5 St Matthews Road Score 3 X 3 x Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 X 2 x DS0000028056.V250590.R01.S.doc Version 5.0 Page 21 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA3 Regulation 14(1)(a)(d) Requirement Timescale for action 30/12/05 2 YA24 3 YA24 4 5 YA33 YA33 The home must arrange for a detailed assessment to be carried out of one of the resident’s needs and wishes in relation to suitable alternative accommodation. 23(2)(a)(b)(c)(d) A programme must be drawn up highlighting all areas referred to in this report in relation to maintenance, redecoration and replacement of equipment. Particular emphasis must be placed on the redecoration of the one-bedded unit in house three. Timescales for action must be included and a copy of the programme must be sent to CSCI. 23(4)(e) Records held in relation to fire drills must show the time and length of each fire drill undertaken and a full evaluation of staff performance. 18(1)(a) The need for waking night staff must be kept under continual review. 18(1)(a) Staffing levels in house DS0000028056.V250590.R01.S.doc 30/12/05 30/11/05 31/10/05 30/11/05 Page 22 3-5 St Matthews Road Version 5.0 6 YA35 18(1)(c)(i) 7 YA39 24(1) 8 YA42 13(4)(a)(c) 9 YA42 13(4)(a)(c) three must be reviewed and if necessary increased at busy times of the day. Staff in house five must receive training so that they can appropriately assist in house three should there be an emergency situation. A quality assurance system that seeks the views of the residents of the home must be introduced. The manager must confirm to CSCI that the hot water accessible to residents in the three outlets noted during the inspection has been adjusted. In addition that the problem with the water pressure in the top unit in house three is resolved. The home must review their risk assessments in respect of windows above ground floor level. If assessed as needed then window restrictors must be fitted. 15/11/05 30/12/05 30/12/05 15/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 10 11 12 Refer to Standard YA11 YA37 YA40 Good Practice Recommendations The manager should review the procedure for storing some documents held in relation to residents’ finances. The manager should continue to train to NVQ level 4 or its equivalent in management. The revised policies and procedures should to be reviewed by the board of directors and if suitable made available to staff as soon as possible. 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 23 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 3-5 St Matthews Road DS0000028056.V250590.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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