Inspection on 31/07/07 for 38a Woolifers Avenue

This inspection was carried out on 31st July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

38a Woolifers Avenue 24/07/08

38a Woolifers Avenue 06/06/06

38a Woolifers Avenue 07/03/06

38a Woolifers Avenue 09/11/05

38a Woolifers Avenue 07/03/05

38a Woolifers Avenue 14/12/04

38a Woolifers Avenue 29/01/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 38a Woolifers Avenue 38a Woolifers Avenue Corringham Essex SS17 9AU Lead Inspector Michelle Love Unannounced Inspection 31st July 2007 09:30 38a Woolifers Avenue DS0000018119.V344596.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 38a Woolifers Avenue DS0000018119.V344596.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. 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 38a Woolifers Avenue Address 38a Woolifers Avenue Corringham Essex SS17 9AU 01375 640292 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) Family Mosaic Vacant Post Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2006 Brief Description of the Service: The home provides residential accommodation for three adults with learning disabilities. The proprietors have changed their name from New Essex Housing Association, which was a subsidiary housing association of New Islington and Hackney Housing Association, to Family Mosaic. The home facilities include one large living/dining area, three single bedrooms, one shower room and one bathroom. Service users access a range of formal day care placements within the local community. In addition service users are encouraged to access leisure interests and community facilities. The home is situated a short car journey from Corringham Town and Lakeside shopping Centre. Service users have access to a lease car and there are bus and train links to the area. The home has a garden to the rear. The Service User Guide and Statement of Purpose remain under review. The range of fees range from £1, 220.00 to £1, 380.00 per week. A copy of the latest inspection report is available upon request, but this is not attached to the homes Service Users Guide. 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced `key` inspection conducted by Michelle Love, Regulation Inspector over a period of approximately 4.5 hours. At this inspection 23 key National Minimum Standards were inspected. As part of the inspection process a tour of the premises was undertaken and a random sample of records pertaining to care planning, healthcare documentation, staff recruitment, training, complaint records and the homes Statement of Purpose and Service Users Guide were examined. Additionally residents were observed and spoken with, despite in some cases of their communication difficulties, two members of staff were spoken with and following the inspection the inspector spoke with the manager. The manager was unwell on the day of the site visit. Following the inspection, 9 staff surveys and 2 relatives surveys were forwarded to seek people’s views about the running of the care home. It was disappointing to date that no responses have been received. The inspection was conducted with the assistance and co-operation of the senior in charge and support worker. The number of Statutory Requirements as highlighted at this inspection remains unchanged at 7 and the number of Statutory Recommendations has increased from 3 to 7. What the service does well: What has improved since the last inspection? 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 6 It is unclear as to what has improved since the last inspection as this was the inspector’s first visit to the care home. 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 be made available in other formats on request. 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 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 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an adequate Statement of Purpose and Service Users Guide which sets out the aims and objectives of the home, however this needs to be amended/reviewed to contain the most up to date and accurate information. EVIDENCE: The home has a Statement of Purpose and Service Users Guide located within the office. On inspection of both documents, it was evident that both require reviewing and updating. This was confirmed with the manager following the key inspection. Additionally the section relating to complaints needs to be amended to reflect that the Commission for Social Care Inspection no longer has any statutory responsibility to investigate complaints. Any complaints received at the Commission will be referred back to the registered provider or to the local authority/primary care trust if they are contractually involved. A copy of the last inspection report was not attached to either document. The registered provider should consider alternative ways of enabling current residents residing at the care home to under some aspects of the Statement of Purpose and Service Users Guide. For example in the form of a DVD or CD (talking document). The Commission recognises that although some aspects of the Service Users Guide is in a pictorial format e.g. complaints procedure and 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 9 tenancy agreement, current residents have limited cognitive development to understand the actual meaning of the document. No new residents have been admitted to the care home since the last inspection. The inspector was unable to examine the registered provider’s ability to carry out a needs assessment as part of the admission process, however it was noted at the last inspection that an assessment had not been carried out for the last person admitted to Woolifers Avenue. 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a comprehensive system and format for recording individual resident’s health, personal and social care needs. EVIDENCE: On inspection of two individual care plans, both were seen to be detailed, comprehensive and person centred. Both care plans were observed to be regularly reviewed and updated to reflect changes to individual’s care needs and there was clear information recorded depicting staff’s intervention so as to ensure good delivery of actual care. The only issue, requiring additional information, was in relation to a sleep chart for one person. The coding system was confusing and undecipherable, and it was unclear as to what the information recorded actually meant. It was evident that the care plan was a working document and following discussions with both members of staff on duty, staff were able to demonstrate a good understanding of information documented within each care file and of 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 11 individual resident’s needs. Rapport between support staff and residents was observed to be positive and residents were relaxed and happy in staff’s company. Risk assessments were devised for all areas of assessed risk. In all but two risk assessments recorded, risk assessments clearly identified the specific area of risk and how these were to be minimised. It was not apparent from the care plan, that the resident and/or their representative had been involved with the devising of the care plan and associated documentation. The registered provider must explore ways of evidencing resident and/or representative’s involvement. The Commission recognises that as a result of individuals formal diagnosis and poor cognitive and communication difficulties, individual’s ability to make decisions and choices remains fairly limited and residents are very reliant upon support staff to make decisions and judgements on their behalf and in their best interests. Staff were observed to do this well and proactively on the day of inspection. It was positive to note that each resident has received a formal review in 2007. 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 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. 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. The home provides a good range of activities/meaningful occupation both `in house` and within the local community which meets resident’s needs. The menu is varied and the home is able to cater for specialist dietary needs. EVIDENCE: Of those care plans inspected both were observed to include a list of activities undertaken by individuals. Activities available for residents included sensory sessions, going for a walk, music therapy, massage, keyboard playing, 1-1 interaction with staff, nail-care, going out in the home’s vehicle and accessing the community and aromatherapy. It was disappointing that no information was recorded within individual’s care plan pertaining to their personal preferences, likes and dislikes. None of the residents attend formal day care. 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 13 In addition to the above residents are encouraged and enabled to maintain their own personal interests and hobbies. For example listening to music, watching television, knitting etc. The home has an open visiting policy for visitors which enables residents to receive members of their family and friends at any reasonable time during the day. Although there is information readily available relating to local advocacy agencies, the manager advised the inspector that this is proving difficult to access, however measures continue to be undertaken to secure this for the future. Staff advised the inspector that the registered provider has provided a lease vehicle for residents so that they can access the community. On each shift there is at least one driver on duty so as to ensure that this can happen. The staff rosters confirm the above. Each care plan details individual resident’s nutritional needs. The home was noted to provide for one person who requires a high fibre/low fat/pureed diet and another person who must have a dairy free diet. The inspector was advised by support staff that menus have recently been reviewed and residents have contributed towards this process. In addition to the main menu, alternatives are offered. Nutritional records indicate on a Friday, residents are offered a take away e.g. fish and chips. The homes `rehab` budget of £8.00 each week per resident, funds sweets, drinks and take away meals. The weekly food budget appears to be somewhat meagre to support three residents, two of whom have specialist dietary needs. The registered provider should look at ways of increasing this to enable staff/residents to be creative with the menu. 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who reside at the care home have good access to healthcare professional services. The homes medication policy and procedures protect residents, although some training needs for staff had been identified. EVIDENCE: The healthcare needs of individual resident’s, was detailed within their care plan. Evidence suggested that people who reside at the care home have access to a range of healthcare professionals as and when required. For example Consultant Psychiatry, Community Nurses, District Nurses, GP, Social Worker’s etc Healthcare records for residents include details of professionals to be visited, purpose of visit, outcome and follow up action if required. The home’s complaint book details that one resident’s GP appointment at the local health centre had been arranged and the community nurse was also to be in attendance, however there appears to have been a lack of communication between the care home and healthcare professionals, resulting in the resident 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 15 not attending their appointment. The manager confirmed to the inspector that it was her mistake and no further occurrences have occurred. The home uses the Monitored Dosage System (MDS) for its administration of medication. It was positive to note that there were no omissions of staff initials on the Medication Administration Record (MAR). Information relating to individual medications utilised at the care home were readily available. The manager was advised following the inspection that medication that is not contained within the MDS blister pack must be signed and dated once opened. The homes medication storage facility although secured to the wall, is not the most secure and could easily be broken into. It is the registered providers responsibility to ensure that appropriate measures are undertaken to rectify this issue. PRN (as and when required) medication protocols for individual residents, was observed to be detailed and comprehensive. Information recorded included the specific name of the medication, date first prescribed, dose, route, frequency, maximum dose, reason for use, criteria to be met before PRN medication can be given, possible side effects, staff responsible for administration, review date and prescribing GP and/or Consultant Psychiatrist. In addition to the above there were clear PRN protocol guidelines from Family Mosaic. A list of those staff deemed competent to administer medication was readily available. On inspection of training records for those staff who administer medication to residents, it was noted that only three staff had recent updated training certificates, whilst others only had an `in house` certificate of competence. The registered provider must ensure that all staff who administer medication receive appropriate training as soon as possible. 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 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. 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 lack of staff training for some people does not safeguard or protect residents from abuse or harm. The complaints procedure is not up to date and requires reviewing. EVIDENCE: The home has a complaints policy and procedure displayed within the home’s office. As stated within the `Choice of Home` section of the report, the complaints policy needs to be amended. Since the last inspection the home has received one complaint and this has already been highlighted within `Personal and Healthcare Support` section of the report. Records relating to the actual complaint were readily available and deemed satisfactory. The home has a copy of Thurrock County Councils Safeguarding policy and procedure. Since the last inspection no Safeguarding issues have been highlighted. Following discussions with staff, both were able to demonstrate a good understanding of the homes policy and procedures. Two residents within the care home present on occasions with lively/challenging behaviour. On inspection of staff training records, evidence suggested not all members of staff have received Safeguarding or challenging behaviour training. 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 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. 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. The home provides an appropriate environment for residents, which is homely, comfortable and safe. EVIDENCE: The home environment is well-maintained, homely, clean, safe and odour free. All individual bedrooms were noted to be personalised and individualised and one resident was able to confirm that they liked their bedroom. Specialist items of equipment were available within the home. 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels meet the needs of those people residing at the care home. There is no comprehensive training plan and much of the training is out of date and systems are poor. The service has a poor recruitment procedure with shortfalls and these do not protect or safeguard residents. EVIDENCE: The inspector was advised by the senior in charge on the day of the site visit, that current staffing levels are 2 members of support staff throughout the day (07.00 a.m. to 21.30 p.m.) and 1 waking member of support staff between (21.15 p.m. and 07.15 a.m.) each day. It is of concern that the manager only appears to have one supernumerary shift each week whereby she works 09.00 a.m. to 16.30 p.m. This is seen as inadequate as the manager’s role is vast and includes a substantial amount of paperwork to be completed, supervision of staff, attending meetings, liaising with professionals etc. Consideration must be given by the registered provider to review the manager’s current work pattern and to increase the manager’s supernumerary shifts. On inspection of four weeks staff rosters for the period 2.7.07 to 31.7.07 inclusive, it was positive to note that on all but one occasion staffing levels 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 19 were maintained. On 30.7.07 it was unclear as to who the second person on duty was on the early shift. The staff rosters also indicate some staff, are on occasions completing 14.5 hour shifts. This is not seen as good practice and potentially places both staff and residents at risk. On inspection of the homes staff training folder and staff training record book, there was clear evidence to suggest training deficits for staff. Not all members of staff were observed to have up to date fire awareness, infection control, health and safety, basic first aid, manual handling, food hygiene or COSHH (Control of Substances Hazardous to Health) training. Additionally some members of staff were noted to have no evidence of training, either detailed in a file or within the homes training folder. Additionally there were training gaps pertaining to those conditions associated with the needs of those people residing at the care home. For example total/effective communication, sensory impairment, learning disabilities etc. Following the site visit the inspector discussed the above issues with the manager, who confirmed that she was aware of training deficits and has requested from head office a list of those staff/training courses, which are required urgently. The manager has booked a number of staff on the following training (personal safety, health and safety, COSHH, fire awareness, safeguarding and professional boundaries and ethics). On inspection of 7 staff recruitment files, gaps were noted. It was observed that the registered provider are still using the Commissions pro forma in order to comply with Regulation 19 and Schedule 4 of the Care Homes Regulations despite the agreement being withdrawn as a result of their lack of compliance to meet the regulatory requirements. The registered provider is reminded that all records as detailed within the above regulation must be held within the home and available for inspection at all times. Gaps were noted pertaining to the manager’s job description being for a care assistant and not that of manager, pro forma’s in place not clearly identifying type of CRB disclosure, date obtained or the disclosure reference number, type of proof of identification for some employees, no evidence of training and/or qualifications for some people, full employment histories not fully explored, references not from the last or most recent employer, no evidence of induction for those newly employed and where there is an induction record this was not in line with Skills for Care. No staff recruitment files were available for two members of staff. Records of induction were available for agency staff utilised at the care home, however there was no evidence of checks having been undertaken by the agency and forwarded to the care home prior to their commencement of a shift. The manager has designed and implemented a supervision tracker form depicting supervision sessions undertaken by individual members of staff. Evidence suggested from five files that staff had received 3-4 supervisions plus 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 20 an annual appraisal. The manager has received 3 supervision sessions since commencing as manager (January 07). Supervision records are held securely within the home. The manager advised the inspector, 4 members of staff have achieved NVQ Level 3 including herself and one member of staff is currently undertaking NVQ Level 3. 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the required experience to run the care home and appears committed and keen to ensure that the home is run in the best interests of the residents. EVIDENCE: The manager advised the inspector that she is currently completing the Registered Manager’s Award and is due to finish in December 07. Following discussions with the manager it was evident that she has a wealth of knowledge regarding the `client group`, over the past 18 years and has worked in both a hospital and residential care setting. 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 22 When questioned the manager advised the inspector that although she `shadowed` the home’s previous manager for a period of two weeks, she did not receive a formal induction into her new role. At the time of writing this report, the manager was successful in becoming formally registered with the Commission for Social Care Inspection to manage the care home. Staff spoken with stated that the manager is approachable and easy to talk to. No other records were examined at this inspection, however it was noted at the last inspection that all records examined were found to be accessible, securely stored and in good order. 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 N/A 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 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 2 34 1 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X X X X X X 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 24 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 YA1 Regulation 4&5 Requirement Ensure that the Statement of Purpose and Service Users Guide is reviewed and updated and contains the latest copy of the homes inspection report. Ensure that where possible residents and/or their representatives are part of the care planning process. Ensure that those members of staff who administer medication receive appropriate training. Ensure that all staff receive training relating to Safeguarding and challenging behaviour. Ensure that the homes recruitment procedures are robust and all records as required by regulation are sought and available for inspection. Previous timescale of 20.12.05, 21.4.06 and 25.7.06 not met. Ensure that all staff receive appropriate training to the work they perform. Previous timescale of 20.12.05 and 21.4.06 not met. 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 25 Timescale for action 07/09/07 2. YA6 15(2)(c) 07/09/07 3. 4. 5. YA20 YA23 YA34 18(1)(c) and (i) 13(6) 19, Schedule 2 01/10/07 01/12/07 14/09/07 6. YA35 18(1)(c) and (i) 01/01/08 7. YA42 12 (1) (a) 13 (4) Arrangements must be in place to ensure that all parts of the home to which service users have access are, so far as is reasonably practicable, free from hazards to their safety. This with particular reference to production of up to date safety certificates for all maintenance inspections undertaken within the home. Previous timescale of 20th December 2005 and 21st April 2006 not met. Not inspected on this occasion. 01/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard YA1 YA17 YA20 YA20 YA22 YA33 YA37 Good Practice Recommendations Consider the use of DVD/CD to enable residents to understand information relating to the homes Statement of Purpose and Service Users Guide. Consider increasing the homes food budget to support the specialist dietary needs of individual residents. Look at securing/making safe the homes medication cupboard. Ensure packets and bottles of medication are signed and dated once opened. Ensure the homes complaints procedure is amended to reflect that the Commission no longer investigates complaints. Consider providing the manager with more supernumerary days/shifts. The manager should complete her NVQ level four qualification. 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 38a Woolifers Avenue DS0000018119.V344596.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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