Inspection on 05/08/05 for 330a Guildford Road

This inspection was carried out on 5th August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

330a Guildford Road 28/06/06

330a Guildford Road 03/10/05

330a Guildford Road 20/12/04

330a Guildford Road 09/08/04

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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 Guildford Road (330a) 330a Guildford Road Bisley Woking Surrey GU24 9AD Lead Inspector Mrs S McBriarty Unannounced Inspection 05 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Guildford Road (330a) Address 330a Guildford Road Bisley Woking Surrey GU24 9AD 01483 489208 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care UK Community Partnerships Ltd Ms Samantha Jayne Moth Care Home 5 Category(ies) of LD - Learning Disability (5) registration, with number of places Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 3. The age/age range of the persons to be accomodated will be : 35-65 YEARS Date of last inspection 20th December 2004 Brief Description of the Service: 330a Guildford Road is located off the main road and approximately one (1) mile from the villages of Bisley and Knaphill. The home provides a living/dining room, kitchen, bathroom, shower room, toilets and five single bedrooms. There is a large rear garden, laid to lawn and ample car parking to the front of the house. The home is provided and managed by Care UK Limited. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection by the Commission for Social Care Inspection (CSCI), the first for 2005-2006. During this inspection 4 residents and three staff were spoken to including the registered manager. The Inspector toured the home and all communal areas were seen. None of the resident’s bedrooms were seen as the residents took the decision not to allow the Inspector to do so. The resident’s have complex needs and are not able to verbally make clear their views and wishes on a number of issues, however they all had good non-verbal skills and were able to make their views known on this matter. A number of documents were sampled as part of the inspection, these include care plans, risk assessments, staff training information, personnel files and various records kept by the home. The Inspector wishes to thank the staff and residents for their welcome to the home. What the service does well: What has improved since the last inspection? The majority of the previous requirements had been met, where this had not happened the matter was discussed and the requirements clarified further. The kitchen had been fully refurbished and the home redecorated. The home is now fully occupied and the staff team and the new resident had been getting to know and understand each other. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 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. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5, Prospective residents have the opportunity to visit the home and for the staff team to observe how they may get on with the other residents. A statement of purpose is provided in audio format to enable the staff to assist residents to understand what the home will provide. The majority of residents do not have a statement of terms and conditions (contract). EVIDENCE: A statement of purpose is provided in both written and audio format. The residents would not be able to understand either version without considerable support. The manager reported that the residents would also find the use of symbols problematic. Information is therefore given over a period of time and verbally by the staff team. The residents needs are assessed prior to their moving in, however the level of information available was sometimes dependent on the information transferred from the previous provider. The home was able to evidence that time was taken to get to know the resident, how they prefer their needs to be met and document this. The majority of residents have lived at the home for some time and were resettled from a long stay provision. The remaining residents have transferred from other providers, as their needs could no longer be met. Given the complex needs of the residents their ability to choose where they live is Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 9 limited. Therefore the decision to move in is made by those professionals responsible for their health and welfare. The residents visit the home before the decision is made to ensure that the home is able to meet their needs. Statements of terms and conditions (contracts) are not available for the majority of residents, where one was evidenced the information was limited and the fee payments had not been completed in full. The manager reported that they are still waiting for social services to complete the contracts; this has been delayed for a year. A previous requirement originally made by CSCI from the inspection on the 8th August 2004 has not been met. The requirement was carried over on the inspection undertaken on the 20th December 2004. A further requirement is made for Care UK to ensure the completion of these documents with social services. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9,10 The resident’s ability to take part in day to day decisions are limited. Further work is required by the home to ensure that this limitation is documented appropriately. Risk assessments and care plans are in place and require updating or further information to ensure that the residents needs have been identified fully. Resident’s files and other records are held securely. EVIDENCE: The files sampled evidenced that detailed care plans and risk assessments have been completed. However there was no evidence to show that residents had been involved in the completion or review of either. A requirement was made during the inspection on the 8th August 2004 and again on the 20th December 2004 that the home provide the residents with all necessary written documents and that all written material has been signed and dated. The requirement had not been met, as the residents are unable to sign. The requirement is therefore clarified to the following: It is required that where appropriate residents agree sign and date their care plans and risk assessments including regular reviews of the same. Where this is not possible and/or there is no independent person to sign on their behalf this must be documented within the care plan and risk assessment. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 11 The resident’s finances are managed by the home and the records sampled were complete and accurate. Access to the majority of these records is by the manager only. Bank records and cash records are kept to ensure that auditing of the finances is straightforward. The resident’s are not able to take part in the running of the home or quality assurance processes provided by the organisation. They are able to take part in some day to day decision making when they feel they are able to or wish to. For example, as stated previously, the residents were able to decide not to let the Inspector into their rooms. The home ensures that all resident’s records are held securely in a locked office. The office is kept locked whenever a staff member is not present in the room as residents may remove items that interest them. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16, 17 Access to social and leisure activities, relationships are limited due to the assessed needs of the residents. This ensures the safety of the residents and others. The residents have complex needs and the staff team ensure that their rights are met where possible. EVIDENCE: The residents are able to take some part in learning new skills and maintaining current skill levels. For example they assist in choosing the menu for the week through the use of pictures. On the day of the inspection one resident was able to make clear that they no longer wanted the choice on offer. The residents in this home are not able to accept employment opportunities or some aspects of further education. A number of leisure and social options are available and staff members assist the residents in seeking appropriate opportunities, for example attendance at a local day centre. The home was working toward providing each resident with a weekly diary of events in a pictorial format. This will enable the residents to see what to expect each day. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 13 The residents in this home would not be able to take part in the electoral system either locally or nationally. As the majority of residents do not have contracts in place the provision required within the contract price was unclear. This includes the provision of a holiday within the fee. A requirement has been made for Care UK to resolve this matter. The residents do not have literacy skills and require the staff team to assist in all aspects of their daily living. Observations throughout the inspection noted that wherever possible choice was encouraged. Relationships between staff and residents were seen by the Inspector to be warm and respectful and responsive. Residents were able to choose when to join either the staff team of other residents; for example one chose to go shopping with a staff member although this had not been planned. The menu’s seen and the arrival of the shopping evidenced that fresh food was used regularly and that the residents were encouraged to assist in shopping, putting food away appropriately and menu planning. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,21 Personal care needs were being met in the way preferred by service users and their health needs were being met. Policies and procedures were in place to support those who may be ageing, ill or dying. EVIDENCE: Standard 20 was not fully assessed. A requirement from the last inspection could not be fully evidenced as being met as the medication returns book was with the pharmacist on the day of the unannounced inspection. The manager reported that the medication returns book was kept up to date and accurate. The care plans sampled evidenced how residents preferred their needs to be met. The health care needs of the residents are assessed and procedures in place to ensure those needs are met. The files sampled showed access to the General Practitioner, optician and dentist as required. The home had completed three health action plans at the time of the inspection; the health action plans provide additional detailed information regarding the needs of the residents. The manager reported that the residents are not able to make the decision as to how they would prefer their death to be dealt with. The home is waiting for Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 15 information or suggestions from family members where they are available. Where this is not possible or the family do not wish to decide on behalf of the resident the manager will consider the best interests of the resident when making plans and ensure they are fully documented. The requirement made at the inspection on the 20th December 2004 that the home maintain a record of the residents wishes concerning terminal care and death has been amended to enable the manager to record either the family views and/or the best interests of the residents. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed during the inspection. EVIDENCE: Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,27,28,29,30 Some work is required to ensure that outstanding repairs are completed, other areas require review to ensure that appropriate options are provided to safeguard residents. The home was clean and hygienic on the day of the inspection. EVIDENCE: The Inspector took a tour of the communal areas; the residents chose not to allow their rooms to be viewed during the inspection. The kitchen has recently been fully refurbished and two doors, one from the grill and the other the fridge have come away and are awaiting replacement or repair. There are occasions when the residents pull hard on doors and they come away from the fittings. The home was seen to provide for the needs of the residents. Some areas require further consideration to ensure appropriate options for safeguarding residents are provided. For example the kitchen cupboard where chemicals are kept is locked with a large chain and padlock. The manager has been seeking suitable alternatives since the kitchen was refurbished. The remaining option is to provide an automatic locking device fitted to the cupboard door. It is important that the cupboard remains locked in the interim. One specified Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 18 resident spent a great deal of time during the inspection seeking a way to open the door. The bathroom has cracked tiles that need repair or replacement and a requirement has been made to ensure this is completed. The bathroom and shower area do not have paper towels provided to ensure that staff are able to dry their hands effectively. The residents require some assistance with personal care and disposable gloves and aprons are provided however hand drying effectively will further reduce the risk of cross infection. The shower area is next to the utility room and residents have to go through the hallway, kitchen and utility room to reach the shower. The residents do have bathrobes to maintain their dignity should they choose to use the shower. The curtains in the living/dining area have come away from the track and in one area the track has come away. Given that the residents often draw the curtains and can pull quite hard it is strongly recommended that the type of tracking and curtaining be reviewed prior to repair or replacement. The residents do not require specialist equipment to meet their needs. The laundry area is adequate to the needs of the home. Soiled laundry is is undertaken in the neighbour home as it has a sluice facility. As yet 330 Guildford Road does not consider that it needs a sluice facility as this is only required on occasion. The office area is very small and it is required that Care UK undertake a health and safety check on staff using the room. Externally the home requires some work. The woodwork near the guttering needs repainting and making good in some areas. The residents use the garden area for relaxation and on occasion to play football. There is a bed of nettles in one corner that require removing to ensure the garden area is safe for the residents use, rubbish both organic and other has been placed at the rear of the garden and requires removal. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32 33, 34, 35, 36 The home ensures that staff training is planned and implemented. Job descriptions for staff members were not available for inspection and a requirement has been made to ensure that Care UK review The Care Homes Regulations 2001 (as amended) regarding recruitment and record keeping. EVIDENCE: Job descriptions were not available within the staff files sampled, the manager confirmed that copies were not kept within the home, however staff do have their own personal copies. It was therefore not possible to assess Standard 31 of the National Minimum Care Standards Younger Adults age 18-65 years. A requirement is made to ensure that copies of the staff members job descriptions are held within the home. Training is provided by Care UK and the NVQ assessor visited the home to discuss assessment plans during the inspection. Three (3) staff had completed either NVQ Level 2 or 3 and five (5) were undertaking NVQ level 2 or 3. Three (3) were also completing the Learning Disability Framework Award (LDAF). A requirement from the inspection on the 20th December 2004 to review the staffing levels had been met. A review of the staffing levels had taken place and from the admission of the new resident staffing levels have increased from 277.5 hours per week to 403.5 per week including waking night staff. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 20 The residents are all British, white males and the staff team reflect a mixed gender and culture. No issues were raised during the inspection regarding the gender and culture of the staff. The staff team were aware of the communication needs of the residents and were observed responding appropriately to requests made by the residents. The recruitment process requires further work to ensure that The Care Homes Regulations 2001 (as amended) are met. For example applications forms request only a seven (7) year employment history from prospective staff members. As noted previously a requirement has been made for Care UK to review the recruitment process in full. A range of training is provided to staff and a new staff member stated that she had received a lot of training on starting work including induction, health and safety, fire etc. The staff member is awaiting further training and has been in discussion with the deputy manager regarding this matter and was confident that there would be no difficulties. Staff training was evidenced through sampling the certificates received by staff and the training matrix available in the office that notes the date of training completed by each staff member. A requirement made at the inspection on the 20th December 2004 has been met. Staff supervision was evidenced at the inspection on the 5th August 2005, although the target of six supervision sessions per year for some staff will need some clear planning to remain on target. It is recommended that where this is the case the deputy manager ensure that dates are booked in order to ensure that the target can be met. The homes supervision year runs from January to December. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 40, 41, 42, The home had an open and inclusive approach where staff and service users were listened to. Staff training information was recorded in full. Further progress is required with regard to maintaining service user records. Action is also required with regard to some parts of the home and garden. EVIDENCE: A requirement made from the inspection on the 20th December for the home to inform the CSCI of any incidents has been met. The registered manager is a qualified social worker and is undertaking the Registered Managers Award. The homes registration certificate was displayed and the manager informed the Inspector that an application for variation of registration was being applied for due the age of a specified resident. The home has a current certificate of Employers Liability Insurance; it is due for renewal in September 2005. A requirement from the inspection on the 20th December 2004 that the organisation provide a quality assurance system could not be fully evidenced. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 22 The manager informed the Inspector that Care UK undertakes a quality assurance programme on a regular basis. The residents of 330a Guildford Road are not able to take part due to their complex needs. The Inspector did not see the organisation’s last quality assurance document during the inspection. It is required that the home forwards a copy of the completed document to the CSCI. As noted previously the majority of residents do not have a contract setting out their terms and conditions and a requirement has been made for Care UK to resolve this matter. The Inspector and manager reviewed the home Whistle blowing or Public Disclosure policy further during the inspection. A requirement had been made during the inspection of the 8th August 2004 and again on the 20th December 2004. This requirement had not been met. It is clear that the policy is not supported by procedures that would enable staff to understand what action they could take and who they could take the matter to should an issue arise. A requirement is made that Care UK provide a supporting procedure to the current public disclosure (whistle blowing) policy. A requirement made at the inspection on the 20th December 2004 has not been fully met. A number of the records sampled during the inspection were not up to date and a requirement had been made to ensure that all records required were documented, up to date and accurate. A requirement is made to ensure that the records kept in the kitchen, for example, fridge and freezer temperatures are recorded regularly. The Inspector found that records had not been kept since April and May of 2005. Opened food found in the fridge did not have a date of opening and although assured by staff that food does not remain for long a requirement was made to ensure that all open food was dated. This would reduce the possibility of food being left open in the fridge beyond a safe period. Records were evidenced of fire evacuation drills taking place, hot water temperatures being sampled regularly and chemical hazardous to health were stored safely in a locked cupboard. A requirement has been made for the provision of paper towels to reduce the risk of cross infection when providing person al care or dealing with soiled items. Three fire doors on the ground floor had been propped open on the day of the inspection. On closing the doors it was apparent that the service users on entering a leaving a room leave the doors to ‘bang’ close. The noise this makes is considerable. A requirement has been made to review the propping open of doors with the fire officer and to consider alternative options for the service users if required. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 2 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 2 3 3 3 Standard No 31 32 33 34 35 36 Score 2 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Guildford Road (330a) Score 3 3 x 2 Standard No 37 38 39 40 41 42 43 Score 3 x x 2 2 2 x H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 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 5, 14 Regulation 5(1)(b)(c) , (3) Requirement The registered person must ensure that a statement of terms and conditions/contract is in place for each service user detailing the issues noted in Standard 5 of The national Minimum Standards Younger Adults age 18-65 years. The CSCI to be kept advised in writing of progress. Timescale of 31st January 2005 not met. The registered person must ensure that service users or their representative, where appropriate, sign and date their care plans and risk assessments including regular reviews. Where this is not possible the reason must be documented in full. Timescale of the 31st January 2005 not met. The registered person must ensure that where appropriate service users wishes are recorded regarding terminal care and death. Where this is not possible a record of the familys views or a record of the best interests of the service user. Timescale of 28th February 2005 Timescale for action 9th September 2005 2. 6,7 15(1)(2) (a)(b)(c) (d), 13(4)(a) (b)(c) 31st August 2005. 3. 21 12(4)(a) (b) 31st August 2005 Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 25 not met. 4. 24 The registered person must ensure that the cracked tiles in the bathroom are repaired or replaced. 23(2)(b) The registered person must ensure that a review take place regarding the current curtains and curtain tracks in the communal areas. Once complete the present curtains and tracking must be repaired or replaced. 23(2)(o) The registered provider must ensure that the rubbish at the back of the garden and the nettles are removed in order to safeguard the service users when they choose to use the garden. 17(2)Sche The registered person must dule 4 ensure that the the records required in Schedule 4 including job descriptions are held at the home. 19(1)(a) The registered person must (b)(c)(4) ensure that a full review take (a)(b)(i) place of the recruitment practice (ii)(iii) of Care UK in order that they Schedule meet The Care Homes 2 Regulations 2001 (as amended) 18(4) The registered person must ensure that the public disclosure policy (whistle blowing) has a supporting procedure in place to ensure staff are made aware of what action to take and how. 17(1)(a) The registered person must (b)(3)(a) ensure that all records required (b) by the home including fridge and frezer temperatures are kept up to date and accurate. 13(3) The registered person must ensure the provision of paper towels to the bathroom and shower room of the home in order to reduce the risk of cross infection. H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc 23(2)(b) 9th September 2005 9th September 2005 5. 24 6. 28 31st August 2005 7. 31 31st August 2005 8. 34 30th September 2005 9. 40 30th September 2005 10. 41 31st August 2005 9th September 2005 11. 42 Guildford Road (330a) Version 1.40 Page 26 12. 42, 24 23(3)(a) 13. 42 23(4)(c) (i)(iii) 14. 39 24(1)(a) (b)(2)(3) The registered person must review the office area to ensure the health and safety of staff members. The registered person must review with the fire officer the propping open of fire doors in the ground floor of the home and consider alternative options if required. The registered person must ensure that a copy of the latest Care UKs quality assurance report is frowarded to the CSCI. 30th September 2004 31st August 2005 31st August 2005 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 36 Good Practice Recommendations it is recommended that dates for supervision are booked by the appropriate person in order to ensure that the home is able meet the requirement for six supervision sessions per year for all staff. Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 27 Commission for Social Care Inspection 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 Guildford Road (330a) H58_s13490_Guildford Road(330a)_v237318_050805_stage4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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