Inspection on 25/04/06 for 3 Clareville Road

This inspection was carried out on 25th April 2006.

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

Other inspections for this house

3 Clareville Road 01/10/07

3 Clareville Road 30/10/06

3 Clareville Road 30/01/06

3 Clareville Road 07/11/05

3 Clareville Road 14/07/05

3 Clareville Road 27/09/04

3 Clareville Road 04/05/04

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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 Clareville Road (3) 3 Clareville Road Caterham Surrey CR3 6LA Lead Inspector Helen Dickens Unannounced Inspection 25th April 2006 10:00 Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 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 Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 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. Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Clareville Road (3) Address 3 Clareville Road Caterham Surrey CR3 6LA 01883 340181 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) The Regard Partnership Limited To Be Confirmed Care Home 10 Category(ies) of Learning disability (10), Mental disorder, registration, with number excluding learning disability or dementia (2) of places Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: 18-65 YEARS Two named individuals may be accommodated who are 17 years of age. Of the ten service users accomodated two named service users currently in residence may also fall within the category MD mental Disorder in addition to LD Learning Disability. 30th January 2006 Date of last inspection Brief Description of the Service: 3 Clareville Road, Caterham is a detached three storey house within the Regard Partnership Ltd, developed to provide accommodation for 10 service users with learning disabilities. The home is sited in a residential road with similar properties, and is within walking distance of local shops and amenities in the town centre of Caterham. Service users’ bedrooms are situated on the ground and upper floors. There is a toilet on the ground floor, and all bathing and showering facilities are situated on the upper floors. This limits the homes suitability for less mobile service users. Communal and recreational areas are situated on the ground floor. Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours and was the first key inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to March 2007. The inspection was carried out by Mrs. Helen Dickens and Mrs. Lisa Johnson, Regulation Inspectors. Mr. Richard Clayton, the new Manager who took up his post 8 weeks ago, represented the establishment. A partial tour of the premises took place and two staff were interviewed. The inspectors spent time with the two service users who were present in the home, with the help of staff who assisted with communication. The other service users were out as the premises was having some decorating done and a carpet fitted on the day of the inspection. A number of documents and files were sampled during the course of the inspection. The inspectors would like to thank the service users, the staff and manager, for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? Care planning documents have improved since the last inspection and half the service users now have a brand new support plan. The plans and other documents are now kept on one file which was a recommendation from the last inspection. Staff files sampled all had the correct documentation as per the requirements made at the last inspection. Training has been planned which covers all the mandatory areas necessary and the manager said the training matrix covering individual staff and the needs assessment for the whole team will be completed within the timescales set at the last inspection. Record keeping has also improved since the last inspection. Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 6 The manager had produced pictorial images depicting food and activity choices and these were being used to assist residents to have more input into the activities of daily living. Some decorative work had been undertaken including one bathroom and the living room. On the day of the inspection a new carpet was being fitted in the dining room. The Regard Partnership has allocated extra resources to this home to support the improvements it requires. The quality assurance officer visited the home the day before the CSCI inspection and carried out a ‘mock inspection’ – this has been followed up by an action plan and arrangements to follow up on all the shortfalls highlighted. 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. Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 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 Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 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 Further work needs to be done to ensure that all service users have a comprehensive assessment of their needs from which to develop their care plans. Without this assessment it is not possible to ensure that each service user’s needs have been correctly identified and can therefore be met. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four service user’s files were sampled and two found not to have a proper assessment from which to devise a suitable care plan. The manager is currently working on ensuring that all residents have a comprehensive assessment and up to date care plan and so far has completed these for four of the eight service users currently living at this home. A further requirement will be made in this regard. Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 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): 6,7 and 9. Care planning has improved but further work needs to be done to meet this standard in full. Opportunities for decision making have increased, therefore improving the quality of life of service users. Risk management strategies in this home need further work. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care planning system has improved since the last inspection and the new manager demonstrated that 4 of the 8 service users now had a new, comprehensive support plan in place. The care planning documents were kept together for each resident which made access more straightforward. The manager said that service users/relatives had not yet signed these plans, but would be doing so soon. The plans were not yet in a resident-friendly format and this would also need to be considered to meet this Standard in full. The new manager demonstrated how he was improving decision making opportunities for service users. The service users meeting held on the evening Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 10 of the inspection gave good examples of how residents were being given some involvement in menu planning and choosing outings. However, the home is still using summer/winter 4 weekly laminated menu cards which is institutional and does not demonstrate flexibility and choice for residents. It was also suggested that the home keep a record of the actual food eaten by each resident each day (e.g. whether they had had the main meal, or the alternative). Further work needs to be done and this was discussed with the manager. Though there were some risk assessments in place, overall, risk management plans needed more work. It was difficult to ascertain if service users had been given good information on which to base their decisions with regard to taking risks, as per Standard 9. On the day of the inspection a number of Immediate Requirements were made which demonstrated the home has not yet done all it possibly can to minimize risks to service users. Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 11 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): 12,13,15,16 and 17. Service users have opportunities to take part in educational activities and be part of the local community. Family links and friendships are supported and service users were treated with respect by staff. Meals offer some choice and variety but residents need to have more involvement. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From examining care plans and speaking with staff it was clear that residents do have educational opportunities and a number of them attend college on a regular basis. Key workers were knowledgeable on the current activities enjoyed by residents. Notes from the service users meeting and care planning documents highlighted opportunities within the local community and staff collected relevant information on such activities. Further work needs to be done to ensure key staff are familiar with and able to support each service user’s goals. In addition, the activities plans for each resident need to be kept up to date and accurately reflect the current position – this is a Requirement under Standard 6. Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 12 Service users are supported to maintain family and friendship links and staff were familiar with the needs and level of involvement of the main relatives/friends in relation to each service user. Service users were observed to be treated respectfully by staff and the manager knocked on every service user’s bedroom door, even though the majority were thought to be out. Staff were interacting positively with service users during the inspection and residents were seen to turn to staff for assistance when needed. No mealtimes were observed during this inspection as the dining room was being re-carpeted and most residents were out. However, residents who returned from college were assisted to have a snack in another part of the house, and staff were knowledgeable on service user’s needs with regard to mealtimes. Notes form the residents meeting showed that residents had been given choices with regard to food, and the manager had devised pictorial images of different food choices to get residents more involved. However, the 4 weekly laminated menu rota (written mainly in words) is still being used, despite it being pointed out that this is rather institutional. It is also not in a format which residents could understand without considerable assistance. There is little evidence of service user involvement in the preparation, planning and serving of their meals and this was discussed with the manager. The old metal gate which separates the kitchen and dining room is still in place. The manager said he would like to replace the gate with a breakfast bar and swing doors and will include this in the refurbishment plans for the home. Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Personal support to service users was provided in a respectful manner by staff. Service users physical and emotional health needs are met. The administration of medication has improved and is now well organised. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The support to service users was observed to be provided respectfully, and personal care provided in the privacy of each resident’s own room. A key working system is in place in this home. Assistance needed was documented on care planning documents but, as stated earlier, these needed further work in order to provide a comprehensive and current picture of each service users needs. A Requirement has been made under Standard 6. Healthcare needs were documented on service users files but not all of those sampled was signed or up-to-date, and some needed reviewing. Medication administration has improved over the last 6 months and Requirements made at the CSCI pharmacy inspection carried out in November 05 have been met. A list of staff authorised to give medicines was available and updated annually; service user records contained a photograph and there Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 14 were no unexplained gaps observed. Protocols were in place for medicines administered ‘as required’. Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 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 the following standard(s): 22 and 23 Service users views are taken into account in this home, but more work needs to be done to fully protect residents. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure is in place and attempts have been made to put this into a more user-friendly format. The resident’s meeting notes contained details of discussions with residents regarding the procedure and staff had identified that residents would need to have this issue highlighted to them again until they fully understood their right with regard to complaints. No complaints had been received since the last inspection. An issue had occurred within the home which had neither been reported to CSCI nor to the local social services team, as set out in the Surrey multiagency procedures for the protection of vulnerable adults. Though the procedure was available in the home the manager had not yet had the relevant training, nor had his staff. To prevent other similar situations arising, the manager needs to arrange for staff to be made familiar with the procedure as soon as possible. Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 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 the following standard(s): 24 and 30 Staff work hard to provide a homely environment for residents but more work needs to be done to meet this standard in full. The home needs to review its practices with regard to cleanliness and hygiene in order to fully protect residents. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises showed that a refurbishment plan was underway; some service users rooms had been decorated, and one bathroom had been painted. On the day of the inspection, carpets were being laid in the dining area. Some parts of the home were nicely decorated and comfortable, including some service users bedrooms. New radiator covers were both tasteful and provided a safe covering for hot radiators. But much work needs to be done. Some areas of the home had torn wall paper, peeling paint and one room had torn privacy screening on the window. Another had a window without curtains, and yet another with inappropriate curtains. Some service user’s bedroom furniture needed attention, including one chest of drawers with a drawer missing. Toilet roll holders had the central Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 17 ‘holder’ missing, and not all hand washing areas had individually dispensed soap and paper towels. The cellar needed clearing and tidying as it could present a fire hazard in it’s current state. The wrought iron gate dividing the kitchen and dining room is unsightly and detracts from the otherwise homely atmosphere which staff are trying to create. The kitchen needed attention with regard to cleaning and food storage and this is outlined later in the report. The garden had large patches of bare lawn and this was discussed with the manager who said a shed was being erected which would cover most of the bare area. The home needs to review its practices with regard to cleanliness. There is no cleaning rota available and the manager said that care staff are expected to keep the home clean. Residents were said to help with some household tasks, but again, this was not documented. At least one toilet was not free from unpleasant odours, and generally the home needed a good clean, especially the kitchen. Hand washing facilities were poor and hot water available to service users was barely warm, and certainly not the recommended 43C. Further linked requirements are made under Standard 42, health and safety. Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 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 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): 32,34,35 and 36 Service users are supported by a competent workforce and though arrangements for staff training and recruitment have improved, further work is needed. Supervision of care staff needs to be restarted in order to meet these standards in full. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users were observed to be comfortable with the manager and staff at this home. The two staff interviewed were approachable to residents and motivated, and assisted inspectors to communicate better with service users, as most residents at this home are non-verbal. Staff files showed a variety of relevant training courses attended by staff. However, crucial protection of vulnerable adults training is needed in order to ensure that service users are safeguarded at all times. Requirements on these matters are made under Standard 35. Staff recruitment has improved considerably since the last inspection and all four files sampled contained the necessary documentation including an enhanced criminal records bureau check. The files were in a standard format which made it easier to check what had happened with regard to each employee. Not all files had a checklist at the front, and one had a checklist Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 19 which was only partially completed. Some files had the same documentation in a different section, and it wasn’t clear whether one staff member had received a new contract due to a change in employment arrangements. Currently only the manager will be involved in recruitment though the new deputy will receive training in recruitment procedures and techniques. The manager has started identifying the relevant training courses required by individual staff members but as yet has not completed a training plan either for individuals or the home as a whole – this work is ongoing and significant progress has been made. Staff records showed that staff received supervision until December 2005 though prior to that it was less than the required number of sessions per year. The manager said staff supervision is being restarted and will happen on a monthly basis. A Requirement will be made in this regard. Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 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 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): 37,39 and 42 The new manager has the experience to bring Clareville Road to the standard required; quality assurance is currently a high priority, and health and safety of residents taken seriously. However, much more work needs to be done. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Regard Partnership has appointed a manager with 15 years experience in the field of learning disabilities, who is enthusiastic and determined in his approach. He already has the Registered Manager’s Award. Improvements are already visible as outlined earlier in the report. He is currently being supervised on a weekly basis by the new service manager at Regard. However, also under Standard 37 is the manager’s responsibility to ensure the home complies with the Care Standards Act and Regulations. On the day of the inspection it became clear that a reportable incident had occurred several days previously, and had not been reported under a Regulation 37 notice. A Requirement will be made in this respect. Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 21 Quality assurance issues are currently the focus of attention at this home and the the day before the CSCI inspection, the The Regard Partnership’s quality assurance officer carried out a ‘mock inspection’ at Clareville Road. This has since resulted in an action plan and arrangements for monitoring progress. The partnership also carries out monthly Regulation 26 monitoring visits. Service user’s meetings also provide an opportunity for their views to be taken into account. A recent nationwide survey by the company showed overall good results but there was no way to determine from the general leaflet (containing the feedback), how this applied to individual homes. A more relevant breakdown of this survey, and a copy of the home’s annual development plan must be sent to CSCI. The new manager takes health and safety matters seriously and a number of issues highlighted on the day were either fixed immediately (warning tape was put on a small step which might be a hazard to visitors); or given priority for that day, for example the fitting of soap dispensers was carried out during the afternoon. However, a number of shortfalls need to be rectified and these are highlighted below; • Unused shower heads need flushing through according to legionella safety procedures. • Cleaning procedures need to be put in place to ensure the correct hygiene management of all areas of the home, especially the toilets and the kitchen. • The kitchen needs to be professionally cleaned, including walls and tiles. • Fridge and freezer temperatures need to be accurately measured and the digital thermometer will need to be in good working order (it was not working on the day of the inspection and a previous Reg. 26 visit had highlighted this issue). • The freezer in the fridge freezer needed urgent defrosting and one drawer was broken, leaving a sharp edge. • Food items which are not in their original packaging, or have been opened, must be correctly wrapped and labelled with contents and date of opening/expiry (e.g cheese, chicken slices, jam roll, biscuits and jars of pickles etc were found unlabelled). • Food removed from the freezer must be correctly labelled and stored (e.g. bread rolls left uncovered on the worktop appeared to be two days out of date). • Individually dispensed soap and hand towels must be available at each hand washing facility, and toilet roll holders must be mended or replaced so that each toilet is fitted with a useable holder. • Water outlets accessible to residents should be controlled according to the relevant Standard – water was only lukewarm on the day of the Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 22 • • • inspection and therefore unlikely to be effective in preventing cross infection. The cellar needs tidying and unwanted, particularly flammable materials such as old cans of paint, should be removed. The hazardous substances cupboard should be kept securely locked at all times. Emergency pull cords for the use of residents must be accessible to them at all times (e.g. not tied up out of reach). The issues highlighted above, not subject to requirements elsewhere in this report, will be covered under Standard 42 in the Requirements section of this report. Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 2 X 2 X X 1 X Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 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 YA2 Regulation 14(1)(a-c)14(2)(ab) Requirement The registered person must ensure that a comprehensive assessment of needs is carried out for all service users where this information is missing from their files. These assessments to be carried out by suitably qualified or suitably trained person(s). (Timescale of 30.01.06 not met. Timescale of 28/02/06 not met.) Timescale for action 25/06/06 2. YA6 14(2)(a-b)15(1)(2) The registered person must ensure that each service user has an individual plan of care and that the plan includes the following: A comprehensive assessment of needs covering all areas of health, personal and social care needs. Risk assessments. Details of each individual need identified. Goal/objective for each DS0000013483.V288704.R01.S.doc 25/05/06 Clareville Road (3) Version 5.1 Page 25 need. Staff actions to be taken to ensure the goals are met. Daily report writing to relate to the staff actions taken and evidence that identified needs and goals are being met. Newly identified needs or problems to be promptly added to the care plan. Signature of service user/representative to signify their agreement with the care plan and risk assessments. (Timescale of 30.01.06 not met. Timescale of 28/02/06 not met.) 3. YA9 13(4)(a)(b)(c) Risk management plans need to be in place covering all areas of risk and more attention must be paid to identified risks including the hazardous substances cupboard, and the kitchen area. The registered person must ensure that all suspected instances of abuse are reported under protection of vulnerable adults procedures, and that all staff are made aware of their responsibilities (i.e. receive training in this regard). Immediate. The responsible individual must ensure that the decorative and maintenance shortfalls identified under this Standard are dealt with in a timely fashion. An action plan must be sent to CSCI within two weeks, DS0000013483.V288704.R01.S.doc 02/05/06 4. YA23 13(6) 25/04/06 5. YA24 23(2)(b)(d) 25/06/06 Clareville Road (3) Version 5.1 Page 26 6. YA30 23(2)(d) 16(2)(j) 7. YA35 18(1)(a)(c)(i) outlining when and how each issue will be addressed; this should include the iron gate. The responsible individual 25/05/06 must review the cleaning arrangements for this home paying particular attention to the kitchen and toilets. A copy of the review should be sent to CSCI. The registered person 30/05/06 must carry out a training and development assessment and profile for each member of staff employed at the home. An action plan must be drawn up and a copy sent to CSCI, Eashing office showing how the identified training needs are to be met. This is carried over from the previous inspection and is still within the permitted timescale for action. The plan should include protection of vulnerable adults training for all staff and should state the current position with regard to NVQ training for all staff. The registered person must carry out a training needs assessment for the staff team as a whole. An action plan must be drawn up and a copy sent to CSCI, Eashing office showing how the identified training needs are to be met. Carried over as above. 30/05/06 8. YA35 18(1)(a)(c)(i) Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 27 9. YA36 18(2)(a) 10. YA37 37(1)(2) 11. YA42 13(4)(a) 12. YA42 13(4)(a)(b)(c) 13. YA42 13(4)(a)(c) 14. YA42 13(4)(a)(b)(c) The registered person must ensure that all care staff are appropriately supervised, and in accordance with this Standard. Supervision should be regular, recorded, and a minimum of six times a year. The registered person must report notifiable events to CSCI as set out in this Regulation. Notifications must be made in a timely fashion, i.e. without delay. Immediate. The registered person should ensure that where emergency call bells are provided, they are accessible to residents. Immediate. The registered person must ensure that all hand washing facilities are furnished with individually dispensed soap and paper towels. Immediate. The registered person must ensure that hazardous substances are securely kept at all times. Immediate. The registered person must send an action plan to CSCI detailing how, and when, the remaining issues highlighted under this Standard in the report will be dealt with. 25/05/06 25/04/06 25/04/06 25/04/06 25/04/06 25/05/06 Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 28 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. Refer to Standard YA6 YA17 Good Practice Recommendations It is recommended that service users’ responsibilities for housekeeping tasks is specified in their individual plans. It is recommended that the home consult a qualified dietician to review and advise on the menu provision at the home. It is recommended that staff include service users in the planning, preparation and serving of their meals and that the format of menus is more user-friendly. It is also recommended that a daily record of what each resident has eaten should be kept. It is recommended that service user’s individual plans incorporate the likes and dislikes of service users who cannot easily communicate their needs and preferences. 3. YA17 4. YA18 Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Clareville Road (3) DS0000013483.V288704.R01.S.doc Version 5.1 Page 30 - 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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