Inspection on 13/10/08 for 55 The Causeway

This inspection was carried out on 13th October 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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 16/12/2008.

CARE HOME ADULTS 18-65 55 The Causeway Carlton Bedfordshire MK43 7LU Lead Inspector Sally Snelson Unannounced Inspection 13th October 2008 11:55 55 The Causeway DS0000071557.V371296.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 55 The Causeway DS0000071557.V371296.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. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 55 The Causeway Address Carlton Bedfordshire MK43 7LU 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) 01234 720246 The Fremantle Trust Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following category: Learning Disability - Code LD The maximum number of service users who can be accommodated is: 6 2. Date of last inspection First under new provider Brief Description of the Service: 55 The Causeway is a residential care home for up to six adults with learning disabilities managed by the Fremantle Trust in conjunction with Bedfordshire Pilgrims Housing Association (BPHA), who are responsible for the maintenance and upkeep of the building. The home is a large bungalow situated in the rural village of Carlton, approximately 8 miles north of Bedford Town Centre. The accommodation comprises of six single bedrooms, two lounge/diners, sensory room, activity room, laundry, kitchen, bathing and toilet facilities and a staff office. The home has a substantial garden and parking for several cars to the rear of the building, accessible through locked gates. The home has developed some user-friendly information for current and prospective service users. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Up until 1st March 2008 55 The Causeway, a home for up to six adults with learning disabilities, was managed by Bedfordshire and Luton Partnership NHS Trust (BLPT). Fremantle now runs it in conjunction with Bedfordshire Pilgrims Housing Association - who are responsible for the maintenance of the building. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which requires review of the key standards for the provision of a care home for younger adults that takes account of residents’ views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. The inspection was a key inspection, was unannounced and took place from 11.55am on 13th October 2008. The manager, Jo Gray, was present throughout, and Liz Harris, the operational manager joined the inspection for a short while, with three Fremantle Trustees who were on a planned visit of the Bedfordshire homes. Feedback was given throughout the inspection and at the end. During the inspection the care of two people who used the service (residents) was case tracked. This involved reading their records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home were observed for their reaction to situations and staff were spoken to and their opinions sought. Any comments received about the home, plus all the information gathered on the day was used to form a judgement about the service. Prior to the inspection two service users and two members of staff had completed surveys. The inspector would like to thank all those involved in the inspection for their input and support. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The following requirements and recommendations have been made as a result of this inspection:•There must be a written plan for all aspects of care. The plan must be detailed, kept updated and involve the resident where possible. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 7 •Service users must be supported to take some appropriate risks. Risk assessments should be written to indicate why certain restrictions are imposed. •The home’s premises must be suitable for its stated purpose; accessible, safe and well maintained; and meet the individual and collective needs of the people living in the home in a comfortable and homely way. This refers to the front garden being enclosed to allow service users access to this area of the garden •Staff must have six meaningful supervisions per year. These must be well documented, and offer them the chance to discuss work and personal issues and training needs. •Staff should continue to consider ways in which service users can be stimulated and take part in even more meaningful activities inside and outside the home. •The complaints procedure should be available in a format suitable for those living at the home. •Consideration should be given to ensuring more of the staff are employed by the Fremantle Trust. •Consideration should be given to the manager becoming the registered manager. •The quality audits should be built upon and show stakeholder involvement. 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. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4. People who use this service experience good quality outcomes in this area. Admissions were not made to the home until a full needs assessment had been undertaken. Prospective residents were given the opportunity to spend time in the home before moving in. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We were provided with a copy of the Statement of Purpose, which had been reviewed and updated on the 6th May 2008 by the manager. The Statement of Purpose was a large comprehensive document. We were not shown a Service Users Guide but we were told it had been updated from the previous one written under BLPT. There had been a new admission to this home since the last inspection so it was possible to assess this standard under the new providers. The manager had assessed the prospective resident while she was staying at an assessment unit. Some staff from the home then went and did some observational shifts at the unit, to get to know her in a care setting. A series of visits were then organised so that the prospective resident had the opportunity to meet the 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 10 other residents. This resident’s parents and an advocate were involved throughout. The staff’s ability to meet the assessed needs of the people using the service is described in the staffing section of this report. The manager had recently demonstrated that she was able to assess that the home’s staff team and environment could no longer met the needs of a resident who had a de-generative condition. This person had been supported to move to a nursing home in an appropriate way. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People who use this service experience adequate quality outcomes in this area. There was evidence that staff knew how to complete the care plans in a person centred way that clearly identified the needs of a particular resident. However this needed to be rolled out to all those people using the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We looked at the care plans for the new resident, and a resident who had lived at the home for a number of years. The contrast between the two plans was great. For example the new resident had plans that had been written in a person centred way and clearly identified the residents needs and aspirations and had been written in sufficient detail to ensure that care needs would be consistently delivered. We were disappointed that other plans had not been updated since the last inspection and were not as person centred. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 12 The plans also included risk assessments and once again this were much more personal for the new admission, and showed how decisions had been made. In order to meet this outcome area all residents must have care files that identify care needs and how they are to be addressed and include an indication as to how the resident has been involved in the process and how decisions have been made. The home had an advocate for all the residents. The advocate supported residents in decisions, such as changes to the environment. In addition each resident had a key worker allocated to support them to establish special relationships and work on a one-to-one basis encouraging them to exercise their rights and make their own decisions. The home tried to actively consult service users on how the service was run. Having resident and key worker meetings and observing service users reactions to all daily situations did this. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 People who use this service experience adequate quality outcomes in this area. People using the service were given the opportunity to take part in a greater variety of activities within, and outside, the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager told us that the home did not have an activity plan as such, but that activities occurred when people using the service indicated that they wanted to do something. We did note that residents were now more involved in the home and staff encouraged them to make drinks, help with shopping, do their own personal shopping and be part of the community. On the day of the inspection one resident was out with a member of staff but we did not witness leisure pursuits other than activities around the home. One resident who was 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 14 upset and did not want to have the planned meal was offered a visit to the pub with a carer, but because she became more upset this did not happen. We did note that the home had built good relationships with the family of the new residents and would support visits to home and involve the family in the new residents day-to-day life as appropriate. The home had good relationships with the local community and were hoping to re-instate drop-in sessions for the villagers to attend for a cup of coffee and get to know the residents. It was hoped that by next summer more residents would spend time in the front garden. (See environmental section of this report) One resident was supported to regularly attend a local church and the manager had involved the religious leader in discussions about how to ensure that this persons religious needs were met. Another person using the service attended church, as he wanted. The people using the service chose from what was in the store cupboard what they wanted for breakfast and lunch, and used picture cards to choose a main meal for each day of the week at a weekly meeting. The home had its own vehicle, which some of the staff were insured to drive. This enabled residents to access the community and services, other than those within walking distance. Residents had drinks when they wished and were encouraged to make their own with staff support. One resident was using a travel kettle to make herself a drink, as the main kettle was too heavy for her. Having the kitchen open, other than when hot dishes are around, had changed the behaviour of one resident who could now request drinks by going into the kitchen and standing by the kettle. A selection of snacks and fruit was available. It remained necessary to keep one kitchen cupboard locked to ensure that some food could be kept for all to enjoy. Individuals care plans and risk assessments should support the decision to keep a cupboard locked. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People who use this service experience good quality outcomes in this area. Health needs were monitored and appropriate actions and interventions were taken to keep people healthy. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: All of the people using the service needed some degree of support with their care and health needs. As already stated some care plans could be more detailed and person centred, but it was apparent from talking to staff that both the permanent and agency staff were aware of the needs of the residents. As the Health Authority had yet to introduce the Health Action Plans outlined in the governments valuing people, staff had produced their own plans for the residents and were looking at ways of supporting the residents to attend well persons clinics. It was the responsibility of the resident’s key worker to support them to make lifestyle choices. We saw evidence that staff were requesting the GP to review the medication of a resident who had lost a 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 16 considerable amount of weight (controlled Loss) and had been seizure free for over 8 years. This review was to ascertain if his medication could be reduced. One person who liked to make a cup of tea for themselves, but found a large kettle too heavy to handle had been provided with a small travel kettle in order to allow them to achieve the task. The medication and medication records of the two service users case tracked were looked at in detail and it was apparent that procedures had improved, and that staff were ensuring that Medication Administration Charts (MAR) were completed accurately. All medications were correctly accepted into the home, administered and stored. We were able to correctly reconcile those medications that were given as required, and from original boxes and bottles. We had been informed correctly when it had been noted that a medication had been forgotten. These omissions were identified quickly and acted upon. The home did not have the facility for storing controlled drugs. Staff had undertaken Non-Aggressive Physical and Psychological Intervention (NAPPI) training so as to not have the need to use restraint on residents. This training had resulted in staff using de-escalation techniques to manage residents challenging behaviour and resulted in everyone appearing much calmer and the use of restraint and ‘as required medication’ had decreased significantly. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use this service experience good quality outcomes in this area. The home’s complaints procedure ensured that people could expect complaints to be dealt with correctly. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Resident and families had been made aware of how they would make a complaint. There was a need to ensure that the complaints procedure was produced in a more user-friendly format to be meaningful to the majority of the residents living at the home. The manager had kept a record of a complaint received from a neighbour, how this had been responded to and what was being done to improve the situation. The manager told us that all the staff had received Safeguarding (SOVA/POVA) training from Beds County Council during 2007, before the home transferred to Fremantle. Training records we saw, and staff we spoke with confirmed they had done this training. The manager was in the process of ensuring that all of the people using the service had their own bank accounts. Because their had been some problems 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 18 with individuals accessing money their had been some delay in rents being paid. We looked at the records of people’s money that the home keeps and they were all satisfactory. We were told that each resident had their own purse which they kept in their rooms with money in to enable thems to “pop” to the shop with support without having to ask for, or be without money. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 19 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): 24,30 People who use this service experience adequate quality outcomes in this area. There were plans to continue to improve the environment to make it more homely and acceptable to the people living there. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: As at the last inspection it was noted that ‘ A Loop system has been put into the lounge to assist those with sensory impairments. There are handrails in the corridors for those with reduced mobility although the layout of the Home makes it difficult for anyone using mobility equipment to move around. It is also difficult to move the hoist around the Home. Staff said that this is only used if a service user falls; it is not used on a regular basis to assist with mobility. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 20 The conditions of registration have been changed to reflect that those service users who have sensory disabilities can remain living at the Home but that no other service users with sensory disabilities can move into the Home.’ Since the last inspection there had been a number of environmental improvements including 1) The office at the front of the house had been moved to the centre of the house, allowing the old office to be used by residents as a sitting /dining room. This had been appreciated by a number of the residents who enjoyed watching people from the window. It also gave residents another area to use, as the lounge/diner was an open plan room and did not offer any areas to escape from others. 2) Also since the last inspection the Kitchen is now open for residents to access when they wish, this enables residents with communication difficulties to go to the kitchen to indicate what they would like or to help themselves. The kitchen can only be locked if it is a health and safety risk i.e., when hot plates are on and there is no staff supervision. 3) The smell in bathrooms noted at the last inspection was not apparent. 4) Housing association meetings were now being held to address environmental issues. Family and the house advocate were encouraged to be involved and support service users to express their views. There were plans for the whole home to be decorated and the lounge carpeted and the ‘Snoezelum’ to be re-established for a relaxation area. The manager told us that she had requested that the front garden be made secure, so that people could spend time in the front of the house and interact with the people from the village and be safe. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 People who use this service experience adequate quality outcomes in this area. There were sufficient staff to meet the needs of the people living at 55 The Causeway and staff rotas could be altered to reflect proposed activities. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The staffing levels had improved significantly under the new providers and the manager confirmed that there was four staff on every shift. Unfortunately because of problems with recruitment and retention these staff were not all permanent staff and there was a heavy reliance on agency. It was not planned that agency staff would be used much longer and there was a new recruitment programme in operation. In order to promote continuity for the people using the service agency staff were block booked wherever possible. On the day of the inspection the manager and one other staff member were permanent, but three other staff came from the agency. The staff provided by the agency were able to talk about the residents needs and told us that they were treated as part of the team and could access training if appropriate. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 22 Staff had between them done a variety of different trainings. Every member of staff has a personal development folder and it was apparent that most training had been updated as and when required. The majority of the staff team had, or were working towards, an NVQ qualification. Each staff member had a personal development file that was his or her responsibility to keep updated. There had been no new staff appointed under the new provider but the manager was aware of the recruitment procedures. Agency staff were expected to produce pro-formas that indicated to the homes manager what training and checks they had had. The manager correctly stored these. A sample of recruitment files indicated that the staff working had the correct checks in place. The manager told that she was now in a position to re-introduce regular staff supervision. At the next inspection we will expect to see that all staff have supervision sessions that are meaningful and cover the areas detailed in standard 36 of the National Minimum Standards. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 People who use this service experience adequate quality outcomes in this area. The manager has the required qualifications and experience to run the home but has not applied to be the registered manager. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The current manager, Ms Jo Gray, had been at the home since the beginning of the year and had managed the transition from BLPT to Fremantle. She had completed the Registered Managers Award (RMA), but had not applied to us to be considered for the position of the registered manager. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 24 When Fremantle took over the management of 55 Causeway a quality audit was carried out. This audit was detailed and referred back to the last report and the National Minimum Standards. What it did show was that very few improvements had been made under the previous providers following the last inspection and many of the improvements noted in this report were as a result of the new management. The service must now continually monitor, assess and plan. We must also see evidence that all stakeholders have been involved in quality reviews. We looked at some of the records the home had to keep. CSCI is being told when there were any incidents in the home, and reports to the safeguarding team had been made as necessary. Inspection of the fire log indicated that fire checks were being routinely carried out. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 3 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 2 32 2 33 X 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 1 X X 3 X 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 YA6 Regulation 15(1) Requirement There must be a written plan for all aspects of care. The plan must be detailed, kept updated and involve the resident where possible. Timescale for action 01/01/09 2 YA9 13(4) 3 YA24 23 This refers to all care plans being written to the same standard as the one written for the new resident. Service users must be supported 01/01/09 to take some appropriate risks. Risk assessments should be written to indicate why certain restrictions are imposed. 01/01/09 The home’s premises must be suitable for its stated purpose; accessible, safe and well maintained; and meet the individual and collective needs of the people living in the home in a comfortable and homely way. This refers to the front garden being enclosed to allow service users access to this area of the garden. Staff must have six meaningful supervisions per year. These must be well documented, and DS0000071557.V371296.R01.S.doc 4 YA36 36 01/01/09 55 The Causeway Version 5.2 Page 27 offer them the chance to discuss work and personal issues and training needs. 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 3 Refer to Standard YA12 YA13 YA22 YA32 YA37 YA39 Good Practice Recommendations Staff should continue to consider ways in which service users can be stimulated and take part in even more meaningful activities inside and outside the home. The complaints procedure should be available in a format suitable for those living at the home. Consideration should be given to ensuring more of the staff are employed by the Fremantle Trust. Consideration should be given to the manager becoming the registered manager. The quality audits should be built upon and show stakeholder involvement. 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 55 The Causeway DS0000071557.V371296.R01.S.doc Version 5.2 Page 29 - 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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