Inspection on 24/10/06 for 64-66 Ragstone Road

This inspection was carried out on 24th October 2006.

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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

64-66 Ragstone Road 20/06/08

64-66 Ragstone Road 21/06/07

64-66 Ragstone Road 31/10/05

64-66 Ragstone Road 26/04/05

64-66 Ragstone Road 12/10/04

64-66 Ragstone Road 13/04/04

Similar services:

21 High Street

Vale House

Chestnut Walk

The Old Vicarage

Cherwood House Care Centre

Ashley House

Ascot Nursing Home

Fountain View

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

CARE HOME ADULTS 18-65 64-66 Ragstone Road Slough Berkshire SL1 2PX Lead Inspector Kerry Kingston Unannounced Inspection 24th October 2006 10:30 64-66 Ragstone Road DS0000011405.V310460.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 64-66 Ragstone Road DS0000011405.V310460.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. 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 64-66 Ragstone Road Address Slough Berkshire SL1 2PX 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) 01753 524869 F/P 01753 524869 Advance Housing and Support Limited Mrs Diane Grist Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st October 2005 Brief Description of the Service: The home is two detached houses linked together by an office/reception area. The home is in a residential area, which is close to local shops at Chalvey and the Town centre of Slough. There are eight beds for people, between the ages of eighteen and sixty-five with mental health needs. The home is run by Advance Housing and Support Limited. The home is staffed 24 hours a day by a team of support workers. The fees are £1,170 per week. 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit took place on the 24th October between the hours of 10.30 am and 7.00pm. The purpose of the visit was to collect information to inform the key inspection report. Information for this inspection was collected by means of an Annual Quality Assurance Assessment, which was partially completed by a previous manager of the service and service user surveys, completed by service users (six of the seven surveys were returned) prior to the visit. On the day of the visit the inspector toured the building, observed care practice, spoke to two service users, two staff and the manager. A family member who was visiting the home was also spoken to. Service user care plans and other records were looked at. The home offers a good standard of care to some service users but it has been without a manager for some months and has a major staff shortage, which has resulted in some areas of care not meeting the needs of individual Service Users. What the service does well: What has improved since the last inspection? What they could do better: The home should have proper assessments for residents before they move in, so they can be sure that they can meet their needs. All the residents should have detailed care plans noting all their needs so that staff can offer them the best possible care. Residents’ healthcare needs should be clearly identified so that staff can help them to get medical attention quickly, if it is required. The home should make sure that the way staff are employed allows them to offer consistent care to the residents. The provider should make plans for the long-term management for the home. 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 6 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. 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 The quality in this outcome area is poor. The home does not, currently, complete detailed assessments of service users to be admitted to the home. Their physical and mental health needs are inadequately assessed and the home may not be able to meet all their needs. This judgement has been made using the available evidence, including a visit to the service. EVIDENCE: The last two people admitted to the home have Community Psychiatric Assessments completed by Berkshire Mental Health Services but no other assessment. An assessment form is completed with service users but there is little detail and no written plan of how the service can meet the needs of the individual. There are no reviews for these two individuals on file. One service user returned to hospital on a section in October 2006 (admitted June 2006), as there was deterioration in behaviour. There are no detailed notes tracking behaviour, help that had been given to the service user, behaviour programmes or staff interventions. There are three incident forms that contain no evaluation of the incidents, or care plan amendments as a result of them. One service user (admitted in May 2006) had a specialist medical need but there was no detail of what special care or advice might be required and if this affected the suitability of the placement. There was no detail of the service users’ mental health needs or how the home could meet them. The service user had to return to hospital in October 2006 because of a medical 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 9 complication, which caused an unpleasant and possibly life threatening incident. Four of the six service users’ Surveys stated that they had received enough information about the home to enable them to choose if they wanted to live there. 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 The quality in this outcome area is adequate. The home reviews and assesses the changing needs and goals of some service users, although this is not always consistent. Staff encourage service users to make decisions and choices for themselves. Service users are assisted to be as independent as is possible. This judgement has been made using the available evidence, including a visit to the service. EVIDENCE: Five care plans were looked at, those service users who have been resident in the home for a long period of time have significantly more detailed care plans. They, generally have an individual support plan, assessment questionnaire completed with service user, a daily activity planner, risk assessments and action plans (objectives for the individual and how to meet them). The total care plan is usually reviewed three monthly by the key worker and the service user. The Community Mental Health Team take responsibility for reviewing the overall care package on an annual basis. This does not always occur and there is sometimes limited detail, relating directly to the residential placement. Service users are kept involved in the care planning process and most sign their care plan and objectives. There is evidence that staff listen to service 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 11 users and change things if it is possible. One service user noted that he wanted monthly instead of three monthly key worker meetings (reviews), this was changed quickly. If service users remain in the care of the home office after admission to the home they have to obtain permission to go out alone or go away from the home. Whilst these service users have reasonable assessments and care plans the care files lack information about hospital admissions (why they occurred) and risk assessments that enable staff to quickly recognise any signs and symptoms of deteriorating mental health. The home works closely with Community Mental and Physical Health Teams and units but often doesn’t have any detail of treatment programmes. One service user said that ‘they are able to make most decisions for themselves, they do what they want and go where they want. They attend reviews and know their care managers.’ She was very aware of who her key worker is and is very confident to approach her. The service users ‘sign off’ their care plan reviews and their objectives and how to meet them. Staff said they encourage service users to be as independent as possible. One service user was observed being encouraged to go to the local shop to purchase her own vegetables and also being encouraged to use the kitchen for food preparation. The home develops appropriate risk assessments to safely support service users’ independence in daily living skills. One service user was observed challenging the manager to ensure that his privacy was being respected, and he appeared very comfortable to raise the issue. Staff were observed treating service users with sensitivity and respecting their privacy and wishes. 3/6 service user surveys said that they could always make decisions for themselves, 2/6 said that they usually could and 1/6 said that they never could. 6/6 service users surveys said that they could do what they want to do. 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 The quality in this outcome area is good. The home supports Service Users to be as independent as possible and to have as positive and enjoyable lifestyle as is practicable. This judgement has been made using the available evidence. EVIDENCE: Service Users’ have individual activity plans although these are not always reflected in the daily notes. One Service User said ‘we do our own thing’, which is not always the activity planned for. There is evidence of staff working hard to motivate service users and increase their confidence and activities, if possible. One service user described the college course he was attending, this was especially selected by staff to reflect his particular personal interests and skills. Service Users were observed ‘coming’ and ‘going’ all day sometimes accompanied sometimes not (as was appropriate). Service Users are generally able to access the community independently and appropriate risk assessments are in place. One Service User has work experience (currently in hospital), this was mentioned by a relative as an area that she feels could be developed. Many activities focus around the home to support Service Users to develop, re-develop or maintain daily living skills to encourage independence. The home 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 13 organises daytrips but not holidays. The manager and staff said that they were not able to staff holidays of more than a few days. The proprietors’ contribute £300 per person per annum to outings, daytrips and/or holidays. One Service user survey commented that he would like more structured activities but two Service users spoken to said that they had ‘plenty to do and are never bored.’ Family contacts are not always noted on care plans but visits and contacts are recorded in daily notes. One service user discussed her relationship with the family and is able to see them and talk to them, if she wishes. A relative of a service user was visiting the home on the day of the visit, the comments were ‘I always feel welcome’, ‘staff help people to maintain contacts with friends and family’, and ‘staff keep you informed’. There were particularly positive comments about the way the staff had helped a vulnerable service user through a recent personal bereavement, the comments included ‘that the staff were very sensitive’, ‘they were very respectful’ and that they had made sure ‘they were always available, when needed’. Six of the seven Service Users have varying degrees of contact with families and one has an advocate. A set of rules is posted on the notice board, the rules focus on respecting others and are to protect all the Service Users. Service Users had input into the drawing up of the rules, which include no smoking in bedrooms, no illegal substances and no aggression to others. 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 The quality in this outcome area is poor. Personal care support and medication administration is generally good for some Service Users and adequate for others, but health care support is poor. The lack of knowledge about Service Users Health Care needs may hamper the staff teams’ ability to respond in a timely way to emerging health issues. This judgement has been made using the available evidence, including a visit to the service. EVIDENCE: Five care plans were looked at, Service Users do not require ‘hands on’ assistance with personal care. Staff have to encourage some Service Users to ensure they meet acceptable standards of hygiene and others are able to deal with their own personal needs. This was, generally, noted on assessments and transferred to ‘objectives’ and care plans. Some of the necessary help/encouragement with personal care was not noted in great detail, as it is usually an independent area. The new manager is very aware of those that do need personal care support and is attempting to recruit a staff member of the same religious background as a service user who needs special assistance. Health issues and how the staff team help Service Users with them are not noted in any detail. Two Service Users admitted approximately for months ago returned to hospital, a staff member said that the district nurse dealt with one 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 15 and the staff were not aware of any special needs or requirements that the service user may have. The other Service User had mental health Issues that the staff member said the staff were not able to support him with. One Service User has a chronic illness, which is not understood by the staff team. There are no details of the illness and no guidelines of how to support the individual. There are also no descriptions of signs/symptoms or difficulties that the Service User could be experiencing because of the illness. Community health care teams support the Service Users in the home but staff do not know what this involves or how they can support the treatment plan. Visits by health professionals are not always recorded. The staff member and new manager felt that they could not adequately support a service user without proper knowledge of their condition or illness and an ability to react quickly to any signs of deteriorating health. Medication records seen were accurate and no recent medication errors were noted. One Service User, currently, self-medicates. Service Users are encouraged to lead healthy lifestyles. Community Psychiatric Nurses give any necessary injections and the home has no controlled medication. Staff are observed and observations are noted until they are assessed by a senior staff member as being competent to administer medication on their own. The new manager is very aware of equality and diversity issues and specific cultural and/or religious needs are to be included in the newly formatted care plans, a blank example of which was available on the day of the visit. 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality in this outcome area is good. Service Users views are listened to and acted upon, where possible and Service Users are protected from abuse. This judgement has been made using the available evidence, including a visit to the service. EVIDENCE: There has been one recorded complaint since the last inspection, the Commission for Social Care Inspection has received no information about complaints but one vulnerable adults issue has been notified. This issue is ongoing and is being appropriately investigated, no Service Users are in any danger. 3/6 Service User Surveys said staff usually listen to what they say 3/6 that they are sometimes listened to.5/6 service users knew how to make a complaint. One Service User spoken to said she ‘feels very safe’ in the home, she knows how to complain and thinks ‘staff listen to her and act on what she says when she’s sensible’. The complaints procedure is on display on the notice board and has been produced in a Service User friendly format. Staff were able to explain how they would react to a complaint or Vulnerable Adults issue and were very confident that they would take the appropriate action to protect the individuals in their care. Staff receive Protection of Vulnerable Adults Training as a basic training course, on a cyclical basis. 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The quality in this outcome area is good. The home is comfortable, homely, clean and hygienic. This judgement has been made using the available evidence, including a visit to the home. EVIDENCE: All parts of the home were clean and well cared for. One Service User showed me her bedroom, which reflected her personality and preferences and was well looked after. The home was comfortable and homely. 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35 The quality in this outcome area is adequate. There are enough staff on duty to meet the needs of the service users but the teams’ effectiveness may be reduced by the lack of experience and focussed training provided to new staff. The structure of the staff team may affect the consistency of care that the staff team are able to provide. This judgement has been made using the available evidence, including a visit to the service. EVIDENCE: There are a minimum of three staff on duty during daytime hours (8am to 10pm) and one waking night staff with one staff sleeping in. The waking night staff and the sleeping in staff may both be care workers and there is no clear ‘on-call’ system, one staff member who had been sleeping in had only been in post for three months and had limited previous experience. The manager advised that the home had a full time equivalent staffing compliment of six (day staff), this has been reduced from eleven. There are currently two permanent day staff and two permanent night staff in post, there are four vacancies. The home use bank staff to cover the shortfalls but this can result in a large number of people in the home to cover the shifts for a week. The manager and staff member felt that this could remain an issue, even when the home is fully staffed. Only three of the four permanent staff are experienced in working with people with mental health needs. The four permanent staff have started N.V.Q.3 training. The induction 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 19 consists of a tick list and is not a recognised or detailed induction process. Supervision has not been consistent but the new manager has plans to improve its’ consistency. A staff member has recently been appointed as a team leader and will assist the manager with some of the supervisory responsibilities. Basic and health and safety training is provided but few opportunities for the necessary, specific specialised mental health training are available to new staff. Staffing records contained all the necessary information and checks for staff safety, one prospective staff member was observed visiting the home to bring her passport and other necessary documentation. Two staff spoken with felt they had enough experience and training to work with Service Users with mental health needs but these were experienced staff who had received specialist mental health training when they were originally appointed, new staff do not appear to have this opportunity. The manager said he recognised this as a shortfall in the training of new staff and had plans to rectify this when the empty posts were appointed. A Service User spoken to said that there were ‘always staff there if you need help’. 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 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 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): 37,39 and 42 The quality in this outcome area is adequate. The staff have worked very hard to try to ensure that the home is managed well but without a manager some areas of the running of the home have deteriorated. The new manager has plans to ensure that all of the systems and processes are restored. The home ensures the Health and safety of the service users. EVIDENCE: The manager has been in post for two weeks (at time of the visit), he has been appointed temporarily for six months and it is not clear what the longterm arrangements will be. There has been no application to the Commission for Social Care Inspection to register the current manager. The home has been without a manager for two months, and has been managed by the few remaining permanent staff. They have worked very hard to try to ensure that Service Users were not affected by the lack of management and staffing but some areas have understandably deteriorated. 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 21 The new manager is very experienced and well trained and has plans for ensuring proper supervision, reviewing staffing structures, adjusting records and making sure that all systems and procedures are re-instated. Regulation 26 visits are completed regularly at approximately two monthly intervals. The organisation have not undertaken, to ensure the quality of care to Service Users remained at an acceptable standard, the regulation monthly visits even though the service has been without a manager or experienced staff team for several months. Service Users are asked about their satisfaction with the service at all visits, staff are also spoken to. The home has been asked to participate in new way of working called ‘recovery’, no-one is very clear what impact it may have on service (if any) as yet but the manager is aware that he may need to amend the Statement of Purpose and Service User guide to ensure it reflects the service that the home offers. The last business/development plan seen was dated 2002 and no current annual development plan is in place. The Organisation send questionnaires to Service Users/ their families and other professionals but it is not clear what the results are. All Health and Safety checks are up-to-date including a visit by fire officer on 16/06/06, three recommendations were made these to be complied with by 01/11/06. No accidents have been reported since the last inspection, several incidents are recorded but these have not been properly monitored by senior staff, the manager advised that this is to be rectified, imminently. 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 1 3 X 4 X 5 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 3 X 2 X 2 X X 3 X 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 23 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 YA2 14(c) (d) 2 3 YA6 YA19 15 12.1(a) Regulation Requirement To ensure that assessments evidence that the home is able to meet the needs of the service users. To ensure that all service users have a written plan as to how their needs are to be met. To ensure staff have enough information to enable them to promote the health of service users. To review the staffing structure to ensure that suitably experienced, competent and qualified staff members are working in the home. To ensure staff receive training appropriate to the work they perform. To notify the C.S.C.I about management changes in the home. To carry out regulation 26 visits at least monthly, in accordance with the regulation. Timescale for action 01/01/07 01/01/07 01/12/06 4 YA32 18.1(a) 01/02/07 5 6 8 YA35 YA37 YA39 18.1(c) 39 26 (3) 01/02/07 01/12/06 01/01/07 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 24 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. Refer to Standard YA18 YA39 Good Practice Recommendations To ensure hat all service users have a detailed care plan that identify their personal care support needs. To complete the quality assurance process by producing an annual development plan for the home. 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 64-66 Ragstone Road DS0000011405.V310460.R01.S.doc Version 5.2 Page 26 - 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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