Inspection on 30/01/06 for 3 Clareville Road

This inspection was carried out on 30th January 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 9 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 25/04/06

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 Denise Debieux Unannounced Inspection 30th January 2006 09:45 Clareville Road (3) DS0000013483.V276211.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.V276211.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.V276211.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 Mrs Christine Tinson 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.V276211.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 accommodated two named service users currently in residence may also fall within the category MD Mental Disorder in addition 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. 7th November 2005 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.V276211.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 6.5 hours and was the third inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was carried out by Denise Débieux, Lead Inspector for the service. Mrs Sue Polden (Area Manager) and Mr Paul Bushell (Acting Deputy Manager) were present as the representatives for the establishment. The previous manager has now left the home. The acting deputy manager is currently managing the home with support from the area manager and another Regard Partnership Ltd service manager. A new manager has been appointed for the home, pending employment checks and is expected to take up his position by the end of February. A tour of the building took place with three of the nine service users and four on-duty staff being spoken with during the tour. The statement of purpose, service users’ guide, staff files, staff training records, medication records, medication storage, complaint’s log, complaint’s procedure, service user files, and menus were all sampled. The inspector would like to thank the service users and staff for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? Since the last inspection the home has revised their statement of purpose and service users’ guide, amended their complaints procedure and made sure that all staff are aware of and able to access the local protection of vulnerable adults procedures. Medication policies and procedures are now being followed and staff are working more closely to other company policies and procedures. The company has also introduced a more planned support system for the temporary management of the home in the absence of a registered manager. Clareville Road (3) DS0000013483.V276211.R01.S.doc Version 5.1 Page 6 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.V276211.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.V276211.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): 1 The homes statement of purpose and service users’ guide now provide service users and prospective service users with the information they need to make an informed decision about admission to the home. EVIDENCE: Since the last inspection the home have reviewed their statement of purpose and service users’ guide. Together these documents now provide detailed and comprehensive information for prospective service users and their representatives thinking of moving to the home. Clareville Road (3) DS0000013483.V276211.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 and 9 There is no clear or consistent care planning system in place to adequately provide staff with the information they need to ensure that service users’ needs are satisfactorily met. The home must ensure that all service users’ assessed and changing needs and personal goals are reflected in their individual care plan. Service users are supported to take risks as part of an independent lifestyle but the home must evidence that service users have been involved in the risk assessment process. EVIDENCE: Two individual service user plans were sampled at this inspection. The plans are made up of various different documents which are stored in different files in the downstairs office. They are made up of the following: • Essential lifestyle plan, this document is detailed and indicates likes, dislikes and ways for staff to avoid and/or deal with certain situations • Service user plan, this document covers agreed plans of needs and includes the Care Manager’s plans. • Risk assessments. • Daily diary notebook. This is a hard back book where staff should document what has happened during each shift. Clareville Road (3) DS0000013483.V276211.R01.S.doc Version 5.1 Page 10 However, in one of the files sampled the pre-admission assessment could not be found. The inspector was advised that, following the previous inspection, not all pre-admission assessments could be found and it is thought that they may have been destroyed. Plans are underway for new assessments to be carried out but they have yet to be completed. Two of the risk assessments seen, whilst detailed, were inappropriate for service users’ files and identified risks to staff or the home’s property. None of the care plans, or risk assessments had been signed by the service users or their representatives to signify their involvement or agreement. The inspector was advised that the care plans are reviewed on a six monthly basis. However, newly identified problems had not been added to the care plans inspected, actions required of staff to meet needs were not clearly documented and daily report writing did not relate to the care plans or evidence that the identified needs were being met. One care plan could not be found. The fragmentation of the care planning system at the home meant that it was difficult for staff and the inspector to find important information or to establish that appropriate steps had been taken to meet the service users’ needs. It also means that staff are not routinely referring to the care plans when providing care and support to the service users, leading to inconsistency in care. These findings are similar to those found at the last inspection and the previous requirements and recommendation have not been met. The requirements have been carried forward to this report with a limited, extended deadline and must now be addressed without delay. Clareville Road (3) DS0000013483.V276211.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): 15, 16 and 17 Service users are supported and enabled to maintain and develop appropriate personal and family relationships. Systems are in place to ensure that service users’ rights are respected but their responsibilities for housekeeping tasks need to be specified in their individual plans. The meals in the home offer choice and variety but service users need to be more involved in the planning, preparation and serving of their meals. EVIDENCE: Staff support service users to maintain family links and friendships inside and outside the home. Referrals have been made to a local advocacy service for service users that do not have family members nearby or close contact with family. All service users attend college during the week where they are able to establish and maintain friendships outside the home. The daily routines reflect the requirement to promote independence and individual choice, with service users observed to be enabled to make choices of what to do and when. Service users participate in some light housekeeping activities, with assistance from staff. These individual responsibilities need to be included in the service users’ individual plans. Clareville Road (3) DS0000013483.V276211.R01.S.doc Version 5.1 Page 12 On the tour of the home it was seen that the kitchen is separated from the dining room by a large metal ‘fence’ structure, with a gate that is kept locked. This is restricting freedom of movement to all service users and it has been recommended that the presence of this structure be reviewed. If it is felt necessary for it to remain then the restrictions on each service user must be based on individual risk assessments and clearly documented in their individual plans. At present the home uses a four week menu which has been planned by the staff. The menus sampled were seen to be varied and the inspector was advised that if service users do not want something that is on the menu on any particular day, they are assisted to choose an alternative from the food stock available. Recommendations have been made that the home consult a dietician to ensure that the menu offered is balanced and nutritious and that service users are assisted to be more involved in the planning, preparation and serving of the meals. All the service users present at the home on the day of this inspection were busy and involved in individual activities, some with the aid of staff where needed. The staff showed skill in communicating with the service users and all interactions were seen to be calm and caring. Clareville Road (3) DS0000013483.V276211.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 and 20 Personal care and support was seen to be provided in a respectful and sensitive manner. Individual likes and dislikes need to be incorporated into the service user’s individual plans. Sound policies and practices are in place for the administration and management of medications. EVIDENCE: During this inspection, staff were observed to always knock and ask permission to enter service users’ private rooms and all personal care was carried out behind closed doors. Details of each service user’s individual likes and dislikes are recorded in their ‘essential lifestyle plan’. It has been recommended that these known likes and dislikes be included in the service user’s individual plans, especially for service users who cannot easily communicate their needs and preferences. A pharmacy inspection was carried out on the 3rd November 2005 and requirements were made. At this inspection the medication administration records (MAR) sheets, medication storage and individual care plans for ‘as needed’ medication were inspected. All were found to be well-maintained and all requirements from the pharmacy inspection have now been meet. Clareville Road (3) DS0000013483.V276211.R01.S.doc Version 5.1 Page 14 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 All required policies, procedures and practices are in place to ensure that service users feel their views will be listened to and that they are safeguarded, as far as reasonably possible, from harm or abuse. EVIDENCE: Following the last inspection the contact details of the local CSCI office have been added to the complaint’s procedure. The home has a ‘whistle-blowing’ policy and a copy of the latest Surrey Multiagency Protection of Vulnerable Adults Procedure in the office. This is now accessible to all staff and was discussed at a staff meeting where staff were asked to make time to read the procedure and sign to signify their understanding, which half the staff have now done. The inspector was advised that the new manager is booked to attend the Surrey training course in February. Clareville Road (3) DS0000013483.V276211.R01.S.doc Version 5.1 Page 15 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 The location and layout of the home is suitable for it’s stated purpose. The home was found to meet service users’ individual and collective needs in a comfortable and homely way. EVIDENCE: The home was toured and found to be in a good state of repair. All bedrooms were decorated, furnished and personalised to each service user’s choice. During this inspection service users were seen to be entering communal rooms and their own rooms with confidence and at will. It was obvious that the service users have a sense of ownership over their home. At the time of inspection the home was warm and bright with a homely atmosphere. Clareville Road (3) DS0000013483.V276211.R01.S.doc Version 5.1 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, 34 and 35 Arrangements for staff recruitment are not satisfactory and are placing service users at possible risk of harm or abuse. Arrangements have now been made to provide staff with NVQ training but comprehensive training needs assessments of individual staff members and the staff group as a whole need to be carried out to ensure that service users are supported by competent and qualified staff. EVIDENCE: At the last inspection it was identified that none of the care staff were qualified to National Vocational Qualification (NVQ) level 2 or above in care. Since that inspection there are now ten staff currently undergoing training with the remaining, new employees enrolled to commence the course soon. The inspector was advised that all new staff from now on will be automatically enrolled. One member of staff spoken with stated that the company now being used to provide the training are very supportive and come to the home on a weekly basis to provide advice and training. Records regarding staff training were not clearly kept and it was discussed and agreed at this inspection that there needs to be assessments of the training needs of the staff team as a whole and individual training assessments and profiles for each individual staff member. It was further discussed and agreed that it would be best for the new manager to carry out these assessments once he is in post. Requirements have been made with a time scale of four months Clareville Road (3) DS0000013483.V276211.R01.S.doc Version 5.1 Page 17 to allow enough time for the new manager to fully understand the needs of the service and to carry out the assessments. During the inspection four staff files were sampled, three of them for staff who have been employed since the last inspection. On three of the four application forms there were unexplained gaps in employment and the members of staff had not given a full employment history (as required by Schedule 2 of the Care Homes Regulations 2001). On two of the files there was no verification of the reasons the persons had left previous care positions and one file had unexplored discrepancies in the persons’ date of birth. In all cases the home had applied for Criminal Records Bureau certificates and carried out a POVAfirst check. Requirements were made at the last inspection regarding staff recruitment that have not been met and have been repeated at this inspection. It is imperative that the registered person protects the safety of service users by addressing the recruitment practices at the home and obtaining missing information on current staff members without further delay. The inspector was advised that all new staff are provided with induction training that meets Skills for Care guidelines and are appointed a supervising staff member for the duration of their induction. Clareville Road (3) DS0000013483.V276211.R01.S.doc Version 5.1 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, 39, 40 and 41 The absence of a registered manager and stable management staff team has resulted in a lack of clear leadership for the staff which has had a detrimental effect on the continuity of care provided to the service users. The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users. All policies and procedures are in place to ensure that service users’ rights and best interests are safeguarded. The standard of record keeping and documentation is poor, potentially placing the service users at risk. EVIDENCE: The home has been going through a period of considerable instability over the past few months with the registered manager leaving, followed by her replacement starting at the beginning of September and then by him subsequently leaving in December. The deputy manager has also recently left on extended leave and a senior care worker has taken on the role of acting deputy manager. For the past few weeks, the acting deputy manager has been working hard managing the home and trying to bring stability to the service users, with support from the majority of other staff members, the area Clareville Road (3) DS0000013483.V276211.R01.S.doc Version 5.1 Page 19 manager and another Regard Partnership Ltd service manager. A new manager has been appointed for the home, pending employment checks and is expected to take up his position by the end of February. There are monthly service user meetings where the staff encourage service users to raise any issues or concerns and ask for suggestions and ideas that the service users may have on improvements to the service. The Regard Partnership Ltd have a new Quality Assurance Department, which will be doing full audits of the home at least once a year to include the views of all service users. A full survey of service users, their relatives and care managers was carried out last November and the home are awaiting the correlation and results report. The inspector was advised that, when this report has been received at the agency, they will supply copies to each service user and the CSCI, Eashing office. Since the last inspection improvements have made in staff following company policies and procedures. CSCI have been notified of any incidents and staff have been following the correct medication procedures. The inspector was advised that individual occurrences of staff not following procedures have been dealt with on a one-to-one basis and policies and procedures are being reviewed with staff in staff meetings. As mentioned earlier in this report, the standard of reporting, documentation and up to date maintenance of records are poor and need to be addressed, for example: care needs assessments, care planning, daily reporting and staff recruitment files. Clareville Road (3) DS0000013483.V276211.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 X 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 X 3 X 1 X 3 3 1 X X Clareville Road (3) DS0000013483.V276211.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 14(1)(a-c) 14(2)(a-b) Requirement Timescale for action 28/02/06 2. YA6YA9 14(2)(a-b) 15(1)(2) 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) The registered person 28/02/06 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 need. • Staff actions to be taken DS0000013483.V276211.R01.S.doc Version 5.1 Page 22 Clareville Road (3) 3. YA34 19(1)(b) 4. YA34 19(1)(b) 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) The registered person 30/01/06 must not employ a person to work at the care home unless he has obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). (Timescale of 07.11.05 not met) The registered person 28/02/06 must ensure that staff files for all persons employed since 26th July 2004 contain all information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004) and be satisfied as DS0000013483.V276211.R01.S.doc Version 5.1 Page 23 Clareville Road (3) 5 YA34 6 YA35.5 7 YA35.6 8 YA41 to the appropriateness of the references obtained. (Timescale of 19.12.05 not met) 18(1)(c)(i) The registered person 19(1)(b) must ensure that all staff involved in staff recruitment receive training and are fully conversant with, and understand, the requirements of The Care Homes Regulations 2001 and Schedule 2 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). 18(1)(c)(i) The registered person 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. 18(1)(a)(c)(i) 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. 12(1)13(6)18(1)17 The registered person must ensure, by training staff or other methods, that all information, documents and other records specified in DS0000013483.V276211.R01.S.doc 30/01/06 30/05/06 30/05/06 28/02/06 Clareville Road (3) Version 5.1 Page 24 Schedules 3 and 4 of The Care Homes Regulations 2001 are maintained at the care home and are kept up to date and are at all times available for inspection by any person authorised by the CSCI. (Timescale of 30.01.06 not met) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations 2 3 4 5 6 It is strongly recommended that the home review their system for care planning and documentation and establish a system where all relevant information is in one file and readily available to ensure that staff are referring to and following the care plans on a daily basis. (Brought forward from last report) YA6YA16.1 It is recommended that the home review the fencing off of the kitchen area which is restricting access to the kitchen to all service users. Any restrictions to freedom of movement within the home must be clearly detailed in each service user’s individual plan and based on risk assessments. YA6YA16.9 It is recommended that service users’ responsibilities for housekeeping tasks is specified in their individual plans. YA17.1 It is recommended that the home consult a qualified dietician to review and advise on the menu provision at the home. YA17.4 It is recommended that staff include service users in the planning, preparation and serving of their meals. YA6YA18.11(ii) 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. Clareville Road (3) DS0000013483.V276211.R01.S.doc Version 5.1 Page 25 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.V276211.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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