Inspection on 26/07/05 for 4 Vallance Gardens

This inspection was carried out on 26th July 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

4 Vallance Gardens 21/03/07

4 Vallance Gardens 13/01/06

4 Vallance Gardens 11/01/05

4 Vallance Gardens 13/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 4 Vallance Gardens 4 Vallance Gardens Hove East Sussex BN3 2DD Lead Inspector Jennie Williams Announced 26 July 2005 9.30 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. 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 4 Vallance Gardens Address 4 Vallance Gardens Hove East Sussex BN3 2DD 01273 749626 01273 749695 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 Management Group Limited Mrs Sharon Lesley Lacey Care Home 10 Category(ies) of LD (10) registration, with number of places 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That service users are aged between twenty-five (25) and sixty-five (65) years upon their admission. 2. The maximum service users to be accommodated is ten (10). 3. That the category of service users admitted have a learning disability, not falling within any other category. 4. That one service user, who is over the age of sixty-five (65) years at the time of admission but who otherwise falls within the main category may be accommodated. Date of last inspection 11 January 2005 Brief Description of the Service: 4 Vallance Gardens is one of many homes owned by Care Management Group Ltd (CMG). This company took over the running of the home in November 2004. 4 Vallance Gardens is registered to provide accommodation for ten residents with learning disabilities. There are eight single rooms and one double room. Rooms are located over two floors. There is a stair lift available to assist residents to access the first landing, then six steps that must be negotiated independently two access the first floor. The home is located in a quiet residential area of Hove. Local amenities and the seafront are within walking distance of the home. There is nearby access to public bus routes. There is no parking available at the home. Paid parking is available in adjacent streets and also available at the nearby leisure centre. The home has accessed visitor permits for relatives coming to visit from out of town to enable them easy parking. The home has access to its own transport. Residents are provided with an opportunity to attend a day centre. There were 10 residents residing at the home on the day of the inspection. Five were being taken out for the day, and five remained on site. 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 290 Dyke Road will be referred to as ‘residents’. This report is based on the findings of the specified inspection date. This announced inspection took place over approximately 6 hours on the 26 July 2005. Staff files, some policies and procedures, records, care plans, individuals’ personal allowance and medication procedures were inspected. A tour of the home was provided. The environment and some individual rooms were spot-checked. The pre inspection questionnaire was sampled and the Inspector received one comment card from a GP. One comment card was received from a visitor/relative. Staff were spoken with throughout the inspection process. Some residents were spoken with, although limited conversation took place due to the disability needs of some individuals. What the service does well: 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. 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 6 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 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 7 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) 2, 3 & 4 The home has information available to prospective residents and their representatives to make an informed decision if the home is suitable for their needs. All prospective residents are assessed prior to moving into the home. EVIDENCE: The Statement of Purpose and Service User Guide was provided to CSCI when Care Management Group Ltd took over the ownership of the home. These documents were not inspected on this occasion. It was confirmed that these documents incorporate the use of pictures and symbols. The organisation has a central assessment team based in Wimbledon who undertake the initial assessment of prospective residents. The manager and a senior staff member will then undertake an assessment to ensure that the home is suitable for the prospective resident. It was reiterated to the manager the importance of her having the final say on whether an individual is to be admitted or not. Prospective residents/representatives are encouraged to visit the home prior to moving in. Due to the disability of the residents, admissions are generally well planned and the home will not take any emergency referrals or short-term admissions. Staff and management are aware of the importance of a gradual transition for new residents and the impact it can have on current residents residing at the home. 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 8 The home obtains a copy of the social service assessment for all residents and ensures a copy of the review is provided. It was confirmed that social services are currently undertaking residents reviews every 18 months. The home has good support systems in place through use of the organisations specialist health professionals eg. physiotherapist, speech and language therapists. 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 & 10 Residents’ needs are being met by the information contained in the care plans. Due to the disabilities of the residents, limited risk taking can be initiated. EVIDENCE: The home has comprehensive care plans. These are developed and reviewed with input from relatives, if applicable. Residents are involved in the process but some are unable to comprehend a lot of the information. Care plans are very detailed and include photos of the residents. All residents have daily diaries that are kept with the individual. These require to be expanded to include information about individuals’ needs and not just information on what an individual has eaten and drunk for the day. Keeping the daily diaries with the individual encourages good communication between the home care staff and the day centre staff and promotes continuity of care. It was noted that some forms in an individuals file had no name recorded on it. It must be clearly written whom the information refers to. Risk assessments need to be expanded and action taken to reduce risks to be documented. Risk assessments must be dated and signed. Additional risk assessments need to be undertaken for travelling in the bus etc. Shortfalls were discussed with the 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 10 manager at the inspection. It is required that all assessments forms in use are signed and dated, including the year. Communication is limited for some residents. Staff working at the home are able to interpret an individuals’ subtle level of communication and will include residents in the daily routines of the home wherever possible. Decisionmaking is limited for some individuals. Residents are encouraged to make decisions and choices that are within their capabilities. Personal information is kept confidentially at the home. No resident is capable of managing their own finances. There is one person who is the designated the appointee for all residents. Individuals’ monies spot-checked demonstrated that there are clear records kept of money received and spent. Receipts are kept of all financial transactions. Relatives/representatives have chosen not to take control of any resident’s finances. 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 & 17 Residents are provided with opportunities for personal development and to be involved in the local community. Visitors are welcomed at the home. EVIDENCE: Residents are provided with a range of activities they are able to participate in. It is required that a more accurate record of activities be maintained. On the day of the inspection five residents were taken out to Arundel for the day. The day centre provides opportunities for residents to engage in informative and creative activities should they wish. Due to the disability of the individuals’, no one is capable of being involved in employment. The home has its own bus and there is a full time driver available. The home is currently waiting for an updated prospectus from a local college. Residents have previously been encouraged and supported to participate in further education. Residents have daily routines. These routines are flexible, but due to the complex needs of some individuals’, residents respond better when there is a familiar routine in place. A clearer record of activities needs to be maintained. 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 12 Visitors are welcomed at the home. Residents may see visitors in their own rooms if they wish. There is a visitor’s book kept at the entrance of the home that all people must sign when entering and leaving the home. Residents are encouraged to be involved in the local community. It was confirmed that residents are weighed on a monthly basis and specialist advice is accessed if required, via a referral from the GP. The menu provided to the Inspector demonstrated that there is a variety of meals provided throughout the week. The Inspector ate mini kievs and beans for lunch with the residents. Residents were observed to be enjoying their meal. An individual did not wish to eat the meal and requested an apple. This choice was readily provided. Staff were observed to encourage independence at meal times and provided discreet assistance when required. There is equipment available at the home to promote the independence of residents at meal times. 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 & 21 Resident’s needs are being met by the skill mix of staff and support network of health professionals within the CMG organisation. Residents are safeguarded by the medication procedures within the home. EVIDENCE: There are guidelines kept in a separate folder from the care plans that provide guidelines for all staff on the preferred way an individual is to be moved. Staff were observed to follow these guidelines when providing support to individuals. The home does not provide nursing care. Due to the complex needs of some residents, staff are required to have a clear understanding of all needs. Health needs are also met with the good support network throughout the organisation. A comment card from a GP demonstrated that there were no concerns around the care being provided at the home. The comment card received from a relative demonstrated that they are overall satisfied with the care provided at the home. There is no one capable of self-medicating at the home. There are policies and procedures in place to deal with all aspects of handling medication. MAR charts inspected demonstrated that medication was being signed for at the time of administration. All staff that administer medication has been trained and assessed as being competent. It is recommended as good practice that any handwritten MAR charts are double checked and signed by staff that have 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 14 received medication training. Any changes written on the MAR charts must be signed. It was confirmed that there are policies and procedures in place regarding the handling of death of a resident. The home is currently accessing information from family/representatives on the wishes to be followed in the event of a death occurring. Staff have recently received bereavement training. It was reflected in the previous report that particular attention be paid to weight gain and mobility as an implication of the ageing process and the changing needs of residents. It was observed that a resident who has a weight and mobility problem was pushed to the bus in a wheelchair. It was confirmed that this individual can mobilise short distances. Staff must encourage individuals to mobilise whenever possible. 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Residents/representatives are provided with opportunities to air their views. Clear written policies will provide staff with clearer guidance on adult protection procedures. EVIDENCE: There is a complaints procedure available at the home. This needs amending to include the contact details of the local CSCI office. There is a pictorial complaints procedure that residents have access to. There had been one complaint made to the home since the last inspection. It was made from an individual within the community complaining about the noise at the home on occasions. The home found this complaint to be substantiated. There was clear documentation on the action taken to resolve this issue and will continue to be monitored. The adult protection policy and procedure needs to clearly state that all allegations of abuse must be referred to social services, who are the lead agency. Information regarding the POVA list needs to be included in this policy. It was confirmed that the home has a copy of the Brighton and Hove East Sussex Multi-Agency Guidelines for the Protection of Vulnerable Adults. It was confirmed that most staff have received adult protection training provided by the Brighton and Hove Council. In house adult protection training is also provided. Adult protection issues is briefly covered in the induction process. The whistle-blowing policy needs to be amended as it currently only focuses on abuse. It needs to be made clear that whistle blowing can relate to any practices within a home. It is recommended that the contact details of the local CSCI office is included in the whistle blowing policy. 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 28 & 30 Residents will benefit from a more homely environment when the building works are commenced. Residents are unable to access all areas of the home unless they are physically independent to negotiate the stairs. EVIDENCE: The home is located in a quiet residential area of Hove. Local amenities and the seafront are within walking distance of the home. There is nearby access to public bus routes. There is no parking available at the home. Paid parking is available in adjacent streets and also available at the nearby leisure centre. The home has accessed visitor permits for relatives coming to visit from out of town to enable them easy parking. The home has access to its own transport. Residents are provided with an opportunity to attend a day centre. There are eight single rooms and one double room. Rooms are located over two floors. There is a stair lift available to assist residents to access the first landing, then six steps that must be negotiated independently to access the first floor. The present communal space provided falls significantly short of the minimum requirement. This clearly has an adverse impact both on the quality of life for residents and of the services that may be provided. The proposed building 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 17 alterations to address this shortfall and also to provide adequate kitchen and laundry facilities have been outstanding since 2002. CMG propose to undertake building works at the home. The manager has not yet received any plans or timescales for the plans. A copy of these plans and timescales must be forwarded to CSCI. Rooms spot-checked were seen to be personalised to reflect the individuals’ choice and character. There are toilet facilities for staff located on the second floor. It was confirmed that when the residents are not in their room, staff will use the ensuite toilet in the double room on the ground floor. The unsuitability of this practice was discussed during the inspection. Staff must promote the privacy of residents and not use the facilities that are provided for residents. It remains an outstanding requirement that a suitable sluicing facility be provided in the new laundry. It was confirmed that this will be addressed when the building works are commenced. 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 & 35 Residents’ needs are at risk of not being met due to insufficient staffing levels. Thorough recruitment procedures must be followed to safeguard residents. EVIDENCE: Staff spoken with during the inspection process were happy working at the home. Staff were complimentary about the manager of the home and find her approachable. Staff commented that they felt the needs of the residents were being met, but they were sometimes short staffed, especially at weekends. The rota provided to the inspector also demonstrated this shortfall. Management must ensure that there are sufficient numbers of staff on duty at all times. Any resident that receives one to one funding must be provided with their individual carer. This carer must not be included in the numbers for caring for other residents. Staffing levels and dependency of residents must be kept under review and staffing numbers adjusted accordingly. The rota must demonstrate when the manager is working with residents or on a managerial day. The home must continue to work towards achieving the 50 ratio of care staff being NVQ level 2 or equivalent qualified. It was confirmed that there is currently one carer undertaking NVQ level 2 training and one undertaking NVQ level 3 training. An additional three staff have completed NVQ training at 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 19 another establishment and are currently awaiting their certificates. One carer has completed NVQ level 3 training. There were some shortfalls in staff files that were discussed with the manager at the inspection. All staff files must comply with Schedule 2. A letter is received by the head office of the organisation stating that a CRB check has been undertaken. It is recommended that this letter provides information to the manager if it was clear or not and that a POVA check has been undertaken. Staff spoken with confirmed that they are provided with opportunities to attend training sessions. Staff are kept up to date with all the mandatory training requirements. New recruits are supernumerary for the first two weeks. 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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, 39 & 42 Residents and staff benefit from clear leadership within the home. Residents are safe guarded by the systems in place to monitor the health, safety and welfare of residents. EVIDENCE: It was confirmed that CMG are arranging training to ensure managers are provided with opportunities to achieve the required qualifications. The Registered Manager Award should be completed by the end of the year and NVQ level 4 in care will be commenced next year. This has not been reflected as an outstanding requirement as there is evidence that work is being done to ensure the manager has the required qualifications. The manager is registered with CSCI and has relevant experience to manage the home. Staff spoken with found management approachable. CMG head office send out their own quality assurance documentation to residents families/representatives. It was confirmed that this procedure includes the views of other health care professional. Head office provides the home with feedback. 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 21 CSCI received one comment card back from a GP. This demonstrated that the GP had no concerns regarding practices at the home and that staff demonstrate a clear understanding of the care needs of the residents. Any specialist advice provided is incorporated into the care plans. Not all policies and procedures were inspected. Any shortfalls in policies and procedures have been highlighted in the relevant section of the report. The home receives policies and procedures from the head office of CMG. It is recommended that a quick reference guide be implemented so staff can quickly access the relevant policy they require. There is a checklist for undertaking an inventory of resident’s belongings on admission. Some were observed to not have been checked. All inventories must be dated and signed upon completion. It was noted that Tippex has been used in some documentation. It was discussed with the manager that this must not be used. Any amendments to documentation must be crossed out and initialled. The pre inspection questionnaire demonstrates that all relevant health and safety checks are undertaken. 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 22 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 x 3 3 3 x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 3 x 1 x 1 Standard No 11 12 13 14 15 16 17 3 2 3 2 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 2 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 4 Vallance Gardens Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 3 x H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 23 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 YA7 Regulation 17 Requirement That care notes are expanded to include information on the health needs of sevice users. (see content of report) That all forms used are named. That all assessment forms are dated and signed, including the year. That risk assessments are undertaken for travelling in the bus and identify the number of staff required to accompany an individual. The driver must not be included in these numbers. That risk assessments are expanded and action taken to reduce risks be documented. That a more accurate record of activities be maintianed. That the complaints policy includes the contact details of the CSCI office. That the adult protection policy clearly states that all allegations of abuse must be referred to social services. Information about the POVA list needs to be included. That the whistle blowing policy is amended to state that it refers to any practice in the home and Timescale for action 15.09.05 2. YA7 17 15.09.05 3. YA9 13.4(b&c) 30.09.05 4. 5. 6. 7. YA9 YA12 YA22 YA23 13.4(b&c) 17 22.7(a) 13.6 30.09.05 30.09.05 30.09.05 30.09.05 8. YA23 Appendix 2 30.09.05 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 24 not just abuse issues. 9. YA24 23.2(a) That the building improvements works commence without further delay. That a copy of the plans and timescales be provided to CSCI. (Outstanding from previous report) That a suitable sluicing facility is provided in the new laundry. (Outstanding from previous report) That staff do not use the ensuite toilet facilities provided to service users. That service users receiving one to one funding are provided with their individual carer. This carer must not be included in the numbers of staff caring for other residents. That the dependency level of service users and staffing numbers be kept under review and adjusted accordingly. That the rota demonstrates when the manager is working with service users or on a managerial day. That a minimum ratio of 50 of care staff are qualified to NVQ level 2 or equivalent. That staff files comply with Schedule 2. 2005 10. YA30 13.4(a&c) 2005 11. 12. YA27 YA33 23.3(a) 18 15.09.05 15.09.05 13. YA33 18 15.09.05 14. YA33 Schedule 4 (7) 18 19 Schedule 2 15.09.05 15. 16. YA32 YA34 31.12.05 30.09.05 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 YA20 Good Practice Recommendations That hand written MAR charts are double checked and signed by staff who have received medication training. That any written amendments are signed. H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 25 4 Vallance Gardens 2. 3. YA21 YA21 4. 5. 6. 7. YA23 YA34 YA40 YA41 That the manager continues to obtain information regarding the wishes of an individual following death. That in the case of ageing service users, in particular, where excess weight gain is affecting mobility, this should be closely monitored and appropriate exercise encouraged. (Outstanding from previous report) That the contact details of the local CSCI office is included in the whistle blowing policy. That clearer information is provided to the manager regarding the suitably of POVA and CRB checks. That a quick reference guide be provided for the policies and procedure manual. That Tippex is not used on the documentation records for any individual. 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 4 Vallance Gardens H59-H10 S14142 4 Vallance Gardens V227348 260705 stage 4.doc Version 1.30 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. 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!