Inspection on 14/12/05 for 535 High Lane

This inspection was carried out on 14th December 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

535 High Lane 04/12/07

535 High Lane 07/12/06

535 High Lane 18/05/05

535 High Lane 11/01/05

535 High Lane 01/10/04

535 High Lane 28/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 535 High Lane Burslem Stoke-on-trent Staffordshire ST6 7AE Lead Inspector Irene Wilkes Unannounced Inspection 12th December 2005 09:30 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 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 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 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. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 535 High Lane Address Burslem Stoke-on-trent Staffordshire ST6 7AE 01782 862134 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) Choices Housing Association Limited Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD, 2 LD(E) Date of last inspection 18th May 2005 Brief Description of the Service: 535 High Lane is a home for eight people with a learning difficulty that is managed by Choices Housing Association. The house is divided into two separate flats, with one on the ground floor and one on the first floor. There is a laundry situated on the ground floor and this has shared access with the service users living in the upstairs flat. Apart from this sharing of facilities, each flat is individually equipped with four single bedrooms, an assisted bathroom, lounge and dining and kitchen facilities. The grounds are neat and tidy, with a parking area to the side and gardens laid to lawn around the property for the service users to enjoy. The home overlooks the local hospital grounds to one side. There is good access at High Lane to local shops, pubs and churches and the hospital. The town of Burslem is only a few minutes drive away, with all the usual facilities of a small town. The home is on a good public transport route. Both flats are very homely and welcoming and High Lane is indistinguishable from the outside as a care home. Altogether it offers a home based on ordinary life principles. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over an afternoon by one inspector. A tour of the home was made and three service users chatted to the inspector for a brief time. This was a busy time just before Christmas, and as well as four service users being out at various activities the other people living at the home were either busy doing things or just getting ready to go out. The home can have up to eight people living there, and it has that number at the moment, as a new gentleman has just moved in. One of the Deputy Home Leaders was on duty, and she and two other staff were spoken to. There were no visitors to the home on the day of the inspection. The records of the new gentleman and a further male and female resident who talked to the inspector were looked at. How the staff spoke to the residents and the things that they supported them with were seen. Some of the records about people’s medicines, and about how the home makes sure that people who live and work there are kept safe were also looked at. What the service does well: The service users said that they were very happy at the home. ‘I like the staff’ ‘I’m helping to do the meal and I like being able to help’ ‘Yes, I’m still happy, and I’ve got a new bedroom and live downstairs now which is what I wanted.’ The staff help the people living at the home to do the things that they want to do, and they talk to them and respect what they have to say. They use pictures to keep a record of what each person wants to do, such as finding a job, or visiting somewhere new, and then they meet with them every month to see if they have done any of these things, or make plans together to do them. The staff also make sure that if anyone is not happy with something that happens in the home they can say so and something is done about it. High lane is a very nice home to live in. There is lots of room and the chairs and beds and bathrooms are all very comfortable. It’s brightly decorated as well, so people living there enjoy their home. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 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. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 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 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 and 4 Prospective service users have their individual needs assessed, but the home has not given the opportunity to a new resident to make an introductory visit. This means that the new resident and those already living at High Lane have not had the chance to voice their views about the placement at an early stage, which is considered poor practice. EVIDENCE: There had been a new gentleman admitted to the home since the last inspection. The man had been a resident of another home some distance away and his family had requested a move to High Lane as it is nearer to the family and in the area in which the man had spent his earlier years. His care records showed that there was background information about him supplied from the previous placement, and that a Social Worker from Stoke–on-Trent had been involved in the transfer. The records also showed that the manager from High Lane had visited the gentleman at his home to undertake an assessment of his needs and find out his wishes for the future. The staff at the former home had provided some limited assistance with this. While the gentleman himself was not able to tell the inspector, an examination of his records and a discussion with a staff member evidenced that the man had not made a visit to the home before moving in. This was further discussed with the manager who was off duty at the time of the inspection but happened 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 9 to call in, who advised that the transfer to High Lane became semi-urgent and that the decision to admit him without a visit had been a joint one with the Social Worker. He also explained that the gentleman has short-term memory loss and would not be able to remember the visit. The inspector, whilst appreciating the background that led to this decision considers that an introductory visit should have been arranged as part of good practice and that there had been sufficient time for this, and it is a requirement of this report that this procedure is followed for any future admission. The manager said that there would be a ‘settling in’ period, followed by a review of the placement, to also allow the existing service users to be consulted about the compatibility with them of the new resident. It is a requirement of this report that this ‘settling in’ period lasts for a minimum of three months, as required in the standards. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 There is a comprehensive plan in place that has been developed with each service user that is based on their individual needs and wishes, with full information available about the support that they receive with decisions that affect their lives, and a range of risk management strategies in place to support an independent lifestyle. This means that each service user is supported to live the lifestyle that they choose. EVIDENCE: The files of two further service users as well as the new resident were looked at and the people who the files belonged to were also happy to have a brief chat with the inspector. The files showed that for the two long standing residents the home were working hard with the individuals concerned to introduce a revised Person Centred Plan which focussed well on the individual needs and aspirations of each service user. The plans were in a format and language that each service user could understand. A review of the plans was undertaken on a monthly basis. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 11 To help towards meeting the needs of people, and to help support them in making decisions about their lives the home had purchased several resources to work through with them, as relevant. These included books such as ‘Overcoming Low Self Esteem’ ‘Sexuality and Women with Learning Difficulties’ and DVD’s that included ‘You, Your Body and Sex’ and ‘My Life Story.’ It was pleasing to note the efforts that were being made to support each person in their decision-making. For the new service user, his plan showed that the home had introduced various activities, both within and outside the home, to try to determine his likes and dislikes to enable a plan based on his needs and wishes to be drawn up. He had visited various clubs, been out shopping, and visited the Job Centre to see if there was any suitable work available. The evidence showed that good progress had been made in a short space of time in developing a picture of the needs and wishes of the gentleman. The home pays good attention to assessing the individual risks for each person to enable them to take a level of risk as part of an independent lifestyle, but working with them to minimise the risk as far as possible. A range of risk assessments were in place, such as accessing the community alone, undertaking various activities, and for each there was a risk management strategy in place. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13 and 16 Service users enjoy an independent lifestyle based around their own interests and wishes, and they take part in appropriate activities both within the home and in the wider community. EVIDENCE: The four service users who were at home at the visit were busy either getting themselves ready to go out to the Grocott Centre or pursuing activities within the home. For this reason they did not wish to chat to the inspector as much as usual, but said that they remained happy in the home and were continuing with their interests and hobbies. One young man is on the committee at the Grocott Centre and he was waiting for a taxi to take him there for a social evening, and he said that he still enjoyed calling out the numbers for bingo at this event. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 13 A gentleman has been poorly since the last visit and is receiving treatment at the hospital. He said that he was not going out on his own like he used to because of his illness, but staff now went with him. Nevertheless he said that he was still doing some of the things that he enjoys, and he was helping to get the evening meal ready at the time of the visit. The home records all of the activities undertaken by each service user in a dedicated activity book. Records in this confirmed the varied lifestyle of each person, and also act as a prompt for staff to ensure each person takes part in additional leisure outings that they have identified that they want to do in their planning review meetings. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 Service users are kept as safe and well as possible by the attention that the home pays to their health needs and the good practice in dealing with medication. EVIDENCE: The individual plans and a limited discussion with staff and service users showed that personal care and healthcare support is provided on an individual needs led basis. Each person had a 24 hour plan of care in place with appropriate risk assessments for areas of need linked to these, e.g. nutrition screening where needed, management of aggression and violence. The service users generally require prompting only with personal care and one of the service users confirmed that he was supported to the level and the way in which he likes. Information about all of the support given was recorded clearly in each care plan. A key worker system operates to ensure consistency. Each person had a Health Action Plan in place with full information about all aspects of physical and mental health, including dates for reviews and follow up appointments. It was seen that all of the appointments for each person were up to date, e.g. dentist, hospital appointments, medication review. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 15 During the visit a member of staff was heard organising a blood test that had been requested for her by the G.P. None of the service users at the home currently self medicate. Their consent to medication is obtained and recorded in their individual plan. Medication is provided by the pharmacy in individual dosette boxes. Procedures for the storage and recording of all medication given were looked at by sampling and were satisfactory in each case seen. Each MAR (Medication Administration Record) that was sampled had been completed appropriately and there were no gaps in recording. It was confirmed that care staff had received medication training. The manager and deputy manager of the home are both qualified nurses. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22 Service users feel comfortable about raising any concerns and know that if they make a complaint that this will be looked at and the appropriate action taken. EVIDENCE: The home has an appropriate Complaints Procedure and each person has their own copy held in their individual file that they have full access to. A Complaints Book is kept by the home and examination of this showed that four complaints had been received since the last visit. Three of these were complaints between residents about someone else’s behaviour towards them, and one was from a relative about the behaviour of another resident towards her son. The records showed that each of the complaints had been appropriately investigated and addressed. A service user spoken briefly with said that he would tell his key worker or the manager if he was not happy with something. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 High Lane provides the service users with a high standard of living accommodation that is domestic in style and suits their needs. This means that the service users enjoy their home. EVIDENCE: This visit showed once again that High Lane provides a homely, comfortable and safe environment for the service users. The upstairs flat was looked at in more detail, while the communal areas of the downstairs flat were visited. Everywhere was pleasantly decorated and finished in a domestic style. Each has an attractive and spacious lounge and well fitted dining kitchen, and bathrooms too are spacious and suit the needs of the service users. The grounds are tidy and safe and accessible to service users, one of whom confirmed that she still loved her home and helps to care for it. The home has a planned maintenance and renewal programme for the buildings and contents. It was confirmed at this visit that a security light that was awaited to cover the outside grounds had now been approved for fitting. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 18 There is only one laundry on the ground floor. However, there are appropriate arrangements in place to ensure that the use of this is appropriately managed. The laundry floor is fitted with impermeable material and the walls are easily cleanable. Policies and procedures are in place and are followed to control the spread of infection, including the provision of protective clothing and suitable hand-washing provision. The home is very clean throughout. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33 and 36 Service users at the home benefit from the experience and knowledge of a competent and qualified staff team who are well supported in their role by the supervision procedures followed. However, there are some issues about insufficient staff being on duty to fully support the service users needs, and this must be addressed as a requirement of this report. EVIDENCE: The staff on duty had a good rapport with the service users. From discreet observation and listening to conversations it was clear that the service users felt comfortable with the staff, who seemed interested in hearing what they had to say and committed to supporting them appropriately. Discussion with the deputy manager showed that she had a good understanding of the needs of all of the service users and confirmed that all of the staff had the necessary skills to deal with anticipated behaviours. Staff on duty advised the inspector that there were two staff vacancies in the home at the time of the inspection, although a successful recruitment drive had been held and these posts were to be filled early in the New Year. Additional shifts had been undertaken as overtime by staff, and the use of bank and occasional agency staff had been made to help cover the vacant hours. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 20 The inspector was concerned that there were only two staff on duty on each shift on this particular day. This meant that there was only one member of staff available on each floor, to deal with the normal running of the home, to facilitate activities and to support each other should an untoward incident occur. At the time of the visit a number of service users were out, but the staff confirmed that this is not always the case and that there is a concern when they are all in with this limited number of staff that some activities do not take place, and safety issues may arise if there is an untoward incident, particularly in view of the layout of the building. Whilst unexpected absences can understandably lead to difficulty in fully covering occasional shifts, these staff vacancies were known about and better cover could have been arranged. It is a requirement of this report that appropriate staffing levels are maintained at all times. The staff records and training files were not seen on this occasion as they were securely locked away as the manager was not on duty. Choices organisation, however, is committed to staff training, evidenced from previous visits and recent visits made to other Choices homes, and the inspector does not have any concerns about the extent of training for all staff. The staff on duty were able to confirm that all of their mandatory training was up to date, and that they have received specialist training in line with Choices policies. At the last inspection undertaken earlier in the year it was disappointing to find that staff were not receiving regular recorded supervision sessions of at least six per year. It was pleasing to note at this inspection that this has been addressed, and evidence was seen that planned supervision is now taking place for all staff at the required intervals. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 41 and 42 Greater care is needed in providing an audit trail for record keeping and ensuring that environmental risks are reviewed in accordance with the home’s own policies. Nevertheless, the home is well run which means that service users benefit from the systems and practices in place. The application for the manager to undergo the ‘fit person’ process has taken far too long and this is considered a poor response to regulation requirements. EVIDENCE: The home is led by a manager who is a qualified nurse and also has several years experience as a manager of a care home with Choices organisation. He has recently completed his NVQ 4 in management. What is disappointing is that since his move to this home some considerable time ago as manager, he has still not been through the ‘fit person’ procedure for this particular management experience. This failure is linked to administrative errors made both by Choices organisation and the manager himself. The manager has made 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 22 recent assurances that his application for a CRB to be processed via the Commission as is required for a manager, which is delaying the process, will now speedily be completed. It is a requirement of this report that this happens. The manager has a clear job description which sets out his responsibilities as the manager, and he also undertakes regular training to maintain /update his knowledge and skills and competence to run the home. Service users have access to their records and the information held about them by the home, and they contribute to the formulation of their records. All of the records were held securely. The home is reminded, however, to ensure that all records made are dated and signed off at the time of completion to provide a clear audit trail. It was difficult in some instances within individual service user files in particular, to find out which was the current information. This is a requirement of this report. Some maintenance and other mandatory records were looked at and these showed that maintenance of fire systems, cleaning logs, food temperature storage etc. were up to date and appropriate. COSHH (Control of Substances Hazardous to Health) storage and data sheets were satisfactory. Fire bell tests and fire drills were up to date. There were safe practices operating for moving and handling of both people and objects. The incident records were examined and these showed that since the last inspection in May of this year there had been 30 violent incidents, 11 restrictive interventions and 28 ‘near miss’ accidents. On the basis of the records seen, examination of all of these showed that appropriate actions had been taken in each case. This evidence, however, has also supported the view that the home requires at least an additional member of staff on duty on each day shift. Whilst there were a range of environmental risk assessments in place, such as for smoking, use of the barbeque, handling of soiled linen, the review of all of these was some five months out of date, as set by the home’s own date for review. It is a requirement of this report that all of the environmental risk assessments are reviewed. There were no apparent hazards seen at the time of the visit. Evidence was seen in the care plans that individual risk assessments were reviewed on a regular basis. 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 2 x Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 4 x x x x x 4 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 2 x x 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 535 High Lane Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x x x 2 2 x DS0000008214.V272859.R01.S.doc Version 5.0 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 YA4 Regulation 14 Requirement That a minimum three month ‘settling in’ period is offered to the new service user, with the review of the placement also taking into account the views of the existing service users. That an introductory visit should be made to the home by any future prospective service user Appropriate numbers of staff should be available on every occasion to meet the individual needs of the service users and to provide sufficient cover for any untoward incident The manager of the home must undergo a CRB check via the Commission to enable the completion of the ‘fit person’ procedure for the manager to proceed (This has been a requirement of previous inspections and has still not been addressed) Ensure that all records are dated and signed at the time of writing to enable an audit trail and to make clear which are the up to date records. DS0000008214.V272859.R01.S.doc Timescale for action 30/04/06 2 3 YA4 YA33 14 18(1)a 31/03/06 28/02/06 4 YA37 9 and Schedule 2 13/01/06 5 YA41 17(3) 28/02/06 535 High Lane Version 5.0 Page 25 6 YA42 13(4) Ensure that the environmental risk assessments that are out of date for review are audited. 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 535 High Lane DS0000008214.V272859.R01.S.doc Version 5.0 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!