Inspection on 18/05/07 for 374-376 Winchester Road

This inspection was carried out on 18th May 2007.

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

Other inspections for this house

374-376 Winchester Road 18/05/09

374-376 Winchester Road 16/07/08

374-376 Winchester Road 27/11/07

374-376 Winchester Road 24/10/06

374-376 Winchester Road 15/02/06

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Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 374-376 Winchester Road Southampton Hampshire SO16 6TW Lead Inspector Annie Kentfield Unannounced Inspection 18th May 2007 13:30 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 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 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 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. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 374-376 Winchester Road Address Southampton Hampshire SO16 6TW 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) 023 80 789786 Integra Care Management Ltd Mrs Beverley Hambidge Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 2006 Brief Description of the Service: 376 Winchester Road is a small home providing twenty-four hour care and support for up to eight residents with a learning disability and who may have challenging behaviour and complex care needs. The service provider is Integra Care Management Limited a Midlands based company. The home provides a comfortable environment where the residents have a room of their own that has been designed and decorated to meet their individual needs and personal preferences. The home has one bathroom and all residents have their own shower or bathroom facility. There is ample communal space and a large enclosed garden. The building is accessible on the ground floor but does not have a passenger lift or stair lift. 376 Winchester Road is situated close to local community facilities, Southampton Common, Southampton Sports Centre and shopping facilities in Shirley and Southampton. Monthly Fees are from £1,500 to £3,000 with additional and varying charges for chiropody, toiletries, outings and holidays. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is the outcome of an evaluation of the service provided by 376 Winchester Road and includes information received about the service since the last inspection of 24 October 2006. Also included in the evaluation is information provided by the registered provider. An unannounced visit to the home was carried out on 18 May 2007 by one inspector who was in the home from lunchtime to early evening. The inspector spoke to three members of staff, the manager and a representative of the registered provider. The inspector was able to observe some of the daily life in the home with residents and staff; the residents are not able to fully engage in the inspection process or give their views about living in the home. The registered provider was asked to send out written comment cards and four were returned; one from a relative, one from a former care manager with Social Services, and two completed by relatives on behalf of service users. All of the comments received about the home were positive. New legislation has made it a legal requirement for all registered services to fill in an Annual Quality Assurance Assessment (AQAA). The information from the completed assessment is aimed at helping the Commission understand how well providers are meeting the needs of people using their service. The assessment form was sent out in advance of the unannounced visit but was returned late, so could not be discussed during the inspection visit. Unfortunately the form was not fully completed and the registered provider needs to ensure that the form is used to greater effect to provide evidence of clear reporting, and evidence of what the service does well, and what the plans for improvement are. Detailed guidance on completing, and using the AQAA is available on the Commission website www.csci.org.uk What the service does well: These are some of the comments from the surveys received: “They work well with people who have been labelled ‘challenging’ and complex” “They create an atmosphere of well being as a result of quiet and confident staff” The registered provider states that what the home does well is to provide “consistent positive regard”, and that “we support residents who have complex anxieties, and manage behaviour”. Observation of practice in the home demonstrated that the manager and staff know the residents well, communication is good, and the residents appeared happy and comfortable. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 8 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 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. New residents only move into the home following a comprehensive assessment of their care needs. There are sufficient numbers of care staff to meet the residents’ care needs but the home must develop a staff training and development plan to demonstrate that care staff have the skills and expertise to meet the residents’ assessed care needs. EVIDENCE: A new resident was in the process of moving into the home during the inspection visit and it was evident that there had been thorough and careful consideration of the resident’s care needs with several opportunities for the resident to visit the home in the previous months. In addition, staff from 376 Winchester had been to visit the prospective resident on several occasions and gathered relevant information from other’s involved in the resident’s care. More staff have been employed since the home has expanded and the registered manager needs to develop a staff-training programme to demonstrate that the staff team are competent, skilled and experienced to meet the complex care needs of the residents in the home. The previous inspection made a recommendation that the information about the home that is available to residents and their relatives, be reviewed, taking 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 10 into account the residents’ varying sensory and cognitive abilities. This has yet to be carried out. The plans for improvement identified by the registered provider state that they would like to offer “more choice” and “more independent living skills”, but the service needs to provide evidence of how they plan to do this. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service recognises the right of residents to make their own decisions and choices. There is some evidence that residents are involved in some decision making about the home such as social activities, in their individual care plans, but the plan does not consistently reflect the care being provided. EVIDENCE: It was evident during a tour of the home that staff are knowledgeable and aware of how residents’ like to take part in the daily living activities in the home and the individual rights of each resident are respected and valued. It was evident that staff are thinking and acting in a person centred way and this needs to be reflected in the individual plans of care. Whilst some work has started; to review and develop each care plan, the manager is aware that more work is needed. Some training for care staff in the area of person centred care planning is needed. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 12 No information was provided by the home in the Annual Quality Assurance Assessment (AQAA) that would have demonstrated how the home meets individual needs and choices and provides their plans for improvement. The AQAA said “Difficult to explain”. In discussion with the manager and provider representative it was explained to the inspector that the service does support the residents to have contact and support from families and independent advocates but there was no evidence in the individual care plans as to how this is recorded and reviewed. It was evident that residents are supported and actively encouraged to develop skills for daily living such as making their own drinks and snacks and residents have their own kitchen to do this. Further development of care plans to identify goals and review them regularly with the residents would demonstrate and confirm what the service is doing well. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally staff are aware of the need to support residents to develop their skills, including social and independent living skills. Some residents are consulted regarding the choice of daily activity, but this process could be improved. EVIDENCE: The information supplied in the Annual Quality Assurance Assessment did not record some of the examples of good practice that were observed during the inspection visit. For example, it was evident that residents are supported and encouraged to develop independent skills such as making drinks or snacks in the residents’ kitchenette, and a dedicated space has been set up in the garden for a resident who likes to ride a bike. A vehicle has been purchased that offers residents greater choice of outings and visits outside the home. Many of the bedrooms contained sensory equipment and music and DVD players that the residents like to use. Some of the residents attend day 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 14 centre, go on holidays, visit their families, go to the shops, pubs and the local park. Clearly there are lots of activities arranged that the residents choose, and enjoy. The home must record what they are doing well as part of their quality assurance process. The manager needs to ensure that choices and activities are clearly recorded in individual care plans and regularly reviewed to ensure that they are meeting the entire specific and varying needs of the residents in the home. This should also involve relatives and other care professionals in the review process as part of the quality assurance. The home has a dining area for the residents. Meals are cooked by care staff and it was evident that fresh food is purchased regularly. The manager plans to develop photo menus and meal choices to assist residents in their choice of meal. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has failed to improve their procedures for safely storing and administering medication, placing service users at risk of harm. The healthcare needs of the residents are monitored and appropriate action and intervention taken. EVIDENCE: There is evidence in the care plans, of health care treatment and intervention and a record of general health care information, including weight checks and medication reviews. Residents have access to a GP, dentist, chiropody and other community services. The previous inspection highlighted concern about gaps in the recording of medication on the medication administration sheets. This has improved but there are still serious shortfalls in the way that medicines are stored and administrated in the home. The manager explained that staff are shown how to administer medicines by observation and shadowing a more experienced member of staff, however, there is no written record made of how staff 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 16 competence is measured. Three of the staff are currently doing a distancelearning course in the safe administration of medication and the home is required to ensure that all staff receive accredited training. Regular checks should monitor that staff are following the home’s medication policy and procedures to ensure that residents are not at risk of harm. There is no clear audit trail of medicines received into the home, dispensed, or returned to the pharmacy, and the manager agreed to put systems into place immediately. The storage is unsafe – the key to the medicine cabinet is left hanging on the wall, in the staff room, that all staff and residents have access to. The manager agreed that safer procedures would be put into place immediately. There is no clear guidance for staff on how and when to give medicines that are prescribed ‘as and when needed’ (PRN). At the moment, only the manager or the responsible individual dispenses PRN medicines, although this may mean that the manager has to come into the home especially. This is not totally satisfactory for residents who may need PRN medication at any time, to be given as soon as possible. There was a reported incident in the home in April when an error was made with medication. The manager responded promptly and appropriate action was taken, however, the manager must provide a written report on the incident and detail what improvement action has been taken. In discussion, the manager confirmed that a Community Nurse has provided some training for staff in the management of diabetes. The training is for 4 named staff, and more accredited training must be arranged to ensure that there is always a trained member of staff on duty. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for protecting residents from harm or abuse could be improved with a staff training and development programme that includes regular updates in knowledge and good practice about safeguarding vulnerable adults. EVIDENCE: There is evidence that the manager of the home is knowledgeable and able to respond promptly and appropriately to any concerns about the well being of the residents. Some of the staff have done specific training about how to recognise and respond to potential or actual abuse, but not all of the staff. This must be included in the mandatory training for all staff and regularly updated. The comment cards received about the service from relatives and a former care manager confirmed that they were aware of the home’s complaints procedure. The last inspection recommended that the service develop ways of making a complaints or concerns procedure accessible to the residents. There are many ways of ensuring that residents are listened to and their views acted upon, and the service must make this part of their good practice and demonstrate this in their quality assurance process. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Thought and consideration have been given to making the home environment safe, comfortable, and homely for the residents. EVIDENCE: Since the last inspection the service has purchased the property next door and the two houses have been converted with an additional ground floor room that links the two together. The new layout provides a spacious home for the residents that is attractive and well furnished. There is a large garden area that is partly laid with paving, with plans to landscape the whole area to provide additional facilities for the residents to use. Residents have their own bedrooms and a choice of communal space, with an additional kitchenette for residents to use. The manager confirmed that windows are fitted with safety glass and window constrictors, and the building and garden are safe and secure for all of the residents. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 19 A tour of the premises confirmed that the home is clean and tidy. Work is still required on the main kitchen and the manager explained that new kitchen units and new flooring are planned. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels have increased and the registered manager must now ensure that there is a staff development and training programme that is focussed on meeting the specific needs of the residents in the home. EVIDENCE: The manager recognises the importance of staff training to ensure that the staff team is skilled and competent in providing the care that the residents need. However, this has yet to be developed and the manager is finding it difficult to access suitable training, partly because she has no training budget, and partly difficulty in finding good quality training providers. Currently, three of the 14 staff are doing a distance-learning course in the safe administration of medication and three staff are doing training in infection control. None of the staff are enrolled to achieve the National Vocational Qualification (NVQ) in care at the minimum level, and there is no training offered in those areas specific to the needs of the residents, such as awareness of autism spectrum disorder, sensory loss, or specific training related to learning disabilities. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 21 The inspector spoke to three members of staff and all demonstrated a commitment and enthusiasm for their work. One new member of staff is in the process of completing an initial induction programme but this was not available to look at. However, a blank copy of the induction programme indicates that the home should be planning their induction training in line with the national standards for care training, provided by ‘Skills for Care’. Although the information supplied by the home in the Annual Quality Assurance Assessment (AQAA) says that the home’s induction training meets the national standards, the evidence contradicts this. Some of the staff have a lot of previous relevant experience and since the last inspection, 6 new members of staff have been employed. The home still employs some agency staff, but the manager explained that the home aims to ensure that all of the staff are permanently employed. Recruitment procedures have improved but records show that they could be more thorough and robust. Not all of the staff have completed the home’s application form and on one recruitment file, a written reference had not been requested from the most recent employer. This was discussed during the inspection visit, as the lack of thorough recruitment procedures has been a requirement over several inspections. The manager must ensure that the process of recruiting new staff protects the safety and welfare of the residents, and meets the regulatory requirements. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has highlighted areas where they need to make improvement and now needs to produce an action plan for undertaking the work. EVIDENCE: The manager has been in post for less than a year and was approved as registered manager in April 2007. The manager has relevant experience and is working towards achieving the minimum qualifications in management and care. Observation of practice in the home showed that the manager has a person centred approach and good communication skills with both residents and staff. The last few months have been difficult for everyone in the home whilst the building work for the expansion of the home has been carried out. Now that this is almost completed, the manager is aware that work is needed to improve and develop systems for staff training, monitoring practice and ensuring compliance with policies and procedures of the home. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 23 The home does not have a deputy manager and it is evident that some thought needs to be given to developing clear lines of accountability and line management within the staff team. For example, there is no one in the staff team with allocated responsibility for medication in the home and as a consequence, no one is checking that all staff that dispense medication are correctly following the policy and procedures for the safe administration of medicines. This has the potential to put the health and welfare of the residents at risk. Although the manager has been able to identify where her priorities for improvement are: developing a trained and competent staff team, developing person centred care planning, developing activities for the residents, she has not had enough time to develop a working plan of action and more work is needed in this area. There has been some improvement to the monitoring of health and safety practice and the manager confirmed that a fire safety risk assessment is in place, and staff are now recording daily fridge and freezer temperatures. However, records show, that not all staff have completed training in all of the mandatory areas of safe working practice such as infection control, food hygiene, first aid, safe moving and handling, or fire safety. Because the manager has not had time to develop a system of monitoring and reviewing the quality of care provided by the home, the service is not able to demonstrate a clear plan of action for identifying what they do well, and what they could do better. The information provided in the Annual Quality Assurance Assessment (AQAA) was not sufficient to demonstrate that the service has identified how well they are meeting the needs of people using their service. Although the AQAA states that the registered providers regularly inspect the home, there is no evidence to demonstrate that the home is monitored regularly to ensure that all statutory requirements have been met within the agreed timescales, and that the service meets all of the National Minimum Care Standards and Care Homes Regulations 2001. 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 2 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 X 2 X 2 X X 2 X 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 25 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 YA20 Regulation 13 (2) Requirement Medication must be safely and appropriately stored and administered. Care staff that dispense medication must receive accredited training in the safe administration of medication. This is a repeat requirement about medication and the previous timescale of 30/12/06 has not been met. The staff training and development programme must be appropriate for the specific needs of the residents and ensure safe working practice. Recruitment procedures must be thorough and robust to protect residents and meet regulatory requirements. This is a repeat requirement and the previous timescale of 30/12/06 has not been met. Timescale for action 30/09/07 2. YA33 YA35 18 30/09/07 3. YA34 19 (1) (b) 30/06/07 4. YA39 24 (1) (a) The home must have a quality (b) (2) (3) assurance system that measures how the service is meeting the needs of the residents. This is a repeat requirement DS0000062649.V336090.R01.S.doc 30/09/07 374-376 Winchester Road Version 5.2 Page 26 and the previous timescale of 30/12/06 has not been 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 YA1 Good Practice Recommendations The registered persons are advised to develop the Service User Guide in an accessible format taking into account the residents’ sensory and cognitive disabilities. The registered persons are advised to introduce person centred planning for each individual and to encourage service users who have the capacity to participate in the ongoing development of their individual plan. The registered persons are advised to thoroughly review each service user’s personal individual plans and archive information, which is not relevant to their existing support needs. The service users would benefit from the home developing and implementing a complaints procedure in a format, which is accessible to them. These are the recommendations from the inspection of 24 October 2006 and are seen as good practice. 2. YA6 3. YA6 4. YA22 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 374-376 Winchester Road DS0000062649.V336090.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!