Inspection on 20/06/05 for 66 St Edmunds Road

This inspection was carried out on 20th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.

Other inspections for this house

66 St Edmunds Road 07/11/07

66 St Edmunds Road 27/03/07

66 St Edmunds Road 28/11/05

66 St Edmunds Road 01/03/05

66 St Edmunds Road 25/08/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 66 St Edmunds Road Stowmarket Suffolk IP14 1NU Lead Inspector Jane Higham Unannounced 20 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 66 St Edmunds Road Address 66 St Edmunds Road Stowmarket Suffolk IP14 1NU 01449 626210 None None Suffolk County Council Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Vacant Care Home 5 Category(ies) of LD Learning Disability (5) registration, with number of places 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 01 March 2005 Brief Description of the Service: 66 St. Edmunds Road is a registered care home for five adults with learning disabilities, owned and administered by Suffolk County Council and situated within a residential area of Stowmarket within easy reach of local amenities and resources. The home was originally opened as a childrens residential resource but was changed to provide care for adults when the original residents moved into the appropriate age group.The accommodation is single storey and comprises of five single bedrooms, communal lounge and dining facilities, two bathrooms and one shower room. There is limited parking to the front of the building. 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection of 66 St Edmunds Rd., a local authority residential home for up to five adults with learning disabilities situated in a residential area of Stowmarket. This was the first inspection in the inspection year 2005/2006. The inspection took place on 20 June 2005 over a period of 4hrs. 15 mins. The inspection was facilitated by the acting manager, Mr. David Gilbert. During the inspection, feedback was sought from residents and one relative who was visiting the home. Resident care plans were examined as were required policies and procedures. Requirements made during the last inspection were revisited and progress assessed. An environmental tour of the home was carried out. What the service does well: What has improved since the last inspection? What they could do better: During the previous inspection which took place in March 2005, eight requirements were made and timescales for meeting the requirements were stipulated. On this occasion it was identified that only two of these 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 6 requirements had been met. Whilst it is acknowledged that on taking over the management of the home, the acting manager’s priority was to ensure the healthy and safety of residents and evaluate the working practices of staff, only limited progress has been made on meeting the outstanding requirements. Additional health and safety issues still need to be addressed such as ensuring that staff receive moving and handling training in order to minimise any risk to either themselves or service users. As a matter of utmost urgency a Statement of Purpose and Service User Guide must be produced which sets out information in relation to services provided at the home. 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. 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3,4 and 5 The home does not have the information available to enable prospective residents to make an informed choice about whether they would like to live there and whether it would be able to meet their needs. No progress has been made in the production of an Admissions Procedure and therefore prospective residents could not receive any assurances on the way in which they would be “introduced” to the service. EVIDENCE: The majority of residents have lived at the home since it was first opened as a children’s residential resource. The resident group remains static and therefore the home is unable to evidence what pre-admission assessments took place before long standing residents moved into the home. However in the previous inspection it was required that the home produce a written admissions procedure which provides a detailed guide to how any new resident should be introduced to the home. It was identified during this inspection that the provision of this procedure remains outstanding. The home still does not have a Statement of Purpose or Service User Guide as required by Regulations 4 and 5 of the Care Homes Regulations 2001.The Acting Manager has written to the parents and advocates of residents informing them that the Statement of Purpose will be available from July 2005. The acting manager advised that the Statement of Purpose will reflect the aim of the local authority to provide residents with a good quality of life, rather 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 9 than a rehabilitative resource from where residents will be expected to move on. The acting manager also advised that the proposed Service User Guide will be produced using more pictures to assist residents in its understanding. Since 01 April 2002, regulation has required that all registered services provide a Statement of Purpose and Service User Guide which sets out the services provided at the home and is made available to all prospective residents, existing residents, families, advocates and stakeholders. The production of these documents is still outstanding and now needs to be produced as a matter of priority. The home was able to evidence that residents are issued with a written contract and a copy of the terms and conditions of placement. 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8 and 9 Residents can not be assured at the present time that their assessed and changing needs will be met and that these individual needs are set out in a detailed plan of care. However, residents can expect to receive the appropriate level of support in order that any risk involved in their activities of daily living can be minimised. Residents are actively encouraged to maintain their independence and to play a role in the running of the home. EVIDENCE: Individual care records of three of the five residents were inspected. These were in various stages of development, making it very difficult to find information to ensure that all aspects of service users health, personal and social care needs are identified and planned for. This was particularly evident with one resident who had received significant input and support from psychology services and the Intensive Support Team. There was no information recorded to inform staff of the outcomes of these meetings. Discussions with the acting manager suggested that care plans were in the process of being reviewed and developed. In the meantime a monthly feedback sheet had been introduced. The information was found to be inconsistent when recording information and ongoing support for each resident in respect of their health and welfare. In the case of one resident, staff had to 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 11 rely on handover sessions, carried out on the change of shift, to determine the current needs of one particular resident. Evidence seen suggested that each resident is actively encouraged to be involved in meeting to discuss their Behaviour Management allowing them to take control of their own behaviour. It was identified that one of the three resident Behaviour Management plan had not been reviewed since 2003. An audit of fees identified a discrepancy in a resident’s invoicing, which the acting manager has investigated. The resident affected is being reimbursed and supported to be involved in the management of their own finances. There was no documentation or risk assessment in their records to evidence this. Since the previous inspection detailed general risk assessments in relation to activities of daily living have been completed for all residents. The home was able to evidence that regular residents meetings are held and residents are consulted about the day to day running of the service. 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 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 standard(s) 11,13,15 and 17 Residents can expect to be supported to play an active role in the running of the home on a risk assessed basis and to access resources and facilities within the local community. Residents can expect to be supported to maintain independence levels, build confidence and improve daily living skills. The home will continue to provide meals of a good standard but on a more pre-planned basis. EVIDENCE: On the day of the inspection three of the residents were attending a day service resource, another was returning from a weekend visit home and the fifth resident was having a “home day”. All residents are provided with a day service on a four day a week basis and each have a “home day” when they are able to attend to their own domestic affairs with a one to one worker. This may include activities such as attending to their laundry or doing personal shopping or the use of local leisure facilities. The resident having a “home day” on the day of the inspection had been out with their one to one worker to buy a new stereo system. During the inspection, one resident and a relative returned from a weekend at home. It was the resident’s birthday. The relative explained that they had 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 13 both chosen to return to the residential home to celebrate their birthday with friends and had brought a cake for all to share. A buffet style tea had been provided which all the residents appeared to enjoy. When asked residents indicated that they enjoyed the meals provided at the home and this was further confirmed by the family member visiting the home at the time of the inspection. Previously menu choices for residents have been on an ad hoc basis but recently the responsibility for meal provision has been passed to a member of staff whose personal development objective is to design a menu format for use by residents which will include symbols and photographs and will assist residents with limited communication to make choices around meal options. The home has a policy of open visiting and was able to evidence that all residents have some involvement with their families and are made welcome when visiting. One family member reported that the situation at the home had improved considerably in recent times and that they now felt able to raise concerns with staff which they had felt reluctant to do before. The family member did express a desire for the home to have more “parents evenings”. During the inspection, the home was able to evidence that residents are enabled to improve their daily living skills, to maintain a level of independence and to be involved in the daily routines. 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 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 standard(s) 20 Residents living at the home can expect their medication to be administered and stored in a safe and secure manner which safeguards their health and welfare. Procedures and practices for the safe administration of intrusive medication can not be evidenced at the present time. EVIDENCE: On the day of the inspection, the systems used for the administration and safe storage of medication were examined and found to be appropriate and secure. Medication is delivered to the home in pre-dispensed blister packs, apart from some medication which must remain in its original packaging. Medication recording sheets are completed each time medication is issued and photographs of each resident are appended to each sheet. Some residents require the administration of rectal diazepam when required. Whilst care staff receive training in this practice from the Community Nurse Team, evidence must be available to show which members of staff have received this training, when the training was provided ,by whom and the content of such training. Evidence must also be available to show which person within the organisation is responsible for insuring that staff receive this training and who holds responsibility for this practice. 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 At the present time, residents residing at the service can not be assured that they will be provided with the appropriate and required information to enable them to raise their concerns or make a complaint either via the home’s management or through other agencies such as the Commission for Social care Inspection. EVIDENCE: On the day of the inspection no evidence was available to show that the home had a clear and robust complaints procedure which was available to all residents, their families and any visitors to the building. Suffolk County Council, who own the home, has its own complaints procedure entitled “Having your Say”. On the day of the inspection this procedure was not available. Regulation requires that the complaints procedure is included as part of the home’s Statement of Purpose but as this document had not been produced, procedures for dealing with complaints was not available in this format. Since the previous inspection, no complaints have been received by the Commission in relation to this service. 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24-30 Residents can expect to be provided with both private and communal accommodation which is homely, comfortable, clean and suited to their individual needs. However, at the present time residents can not be assured that they will be provided with bedroom accommodation which is equipped with basic fixtures and fittings such as carpeting and wash hand basins. EVIDENCE: 66 St. Edmunds Rd. comprises of a single storey domestic style dwelling which is sited in a residential area of Stowmarket and blends well with surrounding buildings. There are five bedrooms all of which are offered for single occupancy. On the day of the inspection, all five bedrooms were pleasantly furnished and decorated and reflected the personal tastes and preferences of the occupant. Whilst none of the bedrooms have ensuite facilities, the home has two communal bathrooms and a shower room (with wheelchair access) and all three rooms are equipped with a toilet. As highlighted in the previous inspection, none of the bedrooms are provided with a wash basin in compliance with standard 26.2 of the National Minimum Standards: Care Homes for Adults. It would appear that bedrooms were never provided with hand basins when the home opened as a children’s resource and that the owning organisation is reluctant to provide these fixtures as there are concerns that 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 17 the safety and welfare of residents would be compromised. During the previous inspection it was agreed that the home would provide the CSCI with a risk assessment which contains a clear breakdown of the risk (if any) that washbasins would pose to the occupants of each room. If no clear risk can be identified then the owning organisation must submit a proposal as to how and when these fixtures will be provided. The home has a good provision of communal space which includes a large living room furnished with armchairs, sofas and a television, a dining room which has good natural light through two sets of doors and windows and a garden room provided with wicker furniture which has patio doors which lead out into the garden. There is also an additional communal room at one end of the building which is at present used as a store room. On the day of the inspection, although some damage had recently been incurred due to the challenging behaviour of one resident, the home was maintained to a satisfactory standard of decorative order and repair. However, as in the previous inspection, it was noted that the bedroom of one of the service users had not been provided with carpeting. When asked, the occupant of the bedroom agreed that they would like carpeting and this was brought to the attention of the acting manager. If carpeting is not to be provided to this room, the service must provide the CSCI with a risk assessment which evidences why the provision of carpet would not be in the best interests of the resident. It was also noted that the three piece suite provided in the communal lounge had torn covers. The home needs to provide new covers for this suite or purchase a replacement. A utility room is equipped with appropriate equipment. It was noted that the home only has two plastic laundry baskets. It was recommended that each resident is provided with a laundry basket (cleanable and with lid) in which their laundry can be moved from their bedroom to the utility room. The home was maintained to a satisfactory standard of cleanliness and hygiene. 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 and 36 Residents living at the home can expect to be supported by a level of staffing which is appropriate to meet their individual needs and to maintain their health, safety and welfare. Residents are protected by the home’s recruitment procedures and staff receive appropriate supervision. To ensure the safety and well being of staff, the owning organisation must provide training in Moving and Handling. EVIDENCE: On the day of the inspection, the home was being staffed by three support workers. This level was maintained throughout the waking day and had been increased on a temporary basis to meet the needs of a resident who was presenting challenging behaviour. During the night period, residents are supported by two members of staff on a “sleep in” basis. Although staffing rotas seen at the time of the inspection correctly reflected the number of staff on duty it did not evidence the number of hours that the acting manager was expected to be in attendance. Two staff personnel files were examined as part of the inspection and found to contain all the required information, including two written references which had been gained by the home before prospective members of staff commenced their duties. All prospective staff members were subject to an Enhanced Disclosure via the Criminal Records Bureau. 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 19 Since the previous inspection, action has been taken to ensure that all staff members receive training in Moving and Handling. One staff member is to undertake a Training for Trainers Course and it is expected that all staff will have received Moving and Handling training by October 2005. The home was able to evidence that one new member of staff was, at the time of the inspection, undertaking Induction Training as provided by Suffolk County Council. Records seen at the time of the inspection evidenced that all staff working at the home receive formal one to one supervision where practice related and personal development issues can be discussed. During the inspection, staff were noted to be clear about their roles and responsibilities and carried out their tasks in confident manner. 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39,41 and42 Residents can expect to live in a home which is effectively managed by a person who is qualified, experienced and competent to carry out these duties. Residents can also expect to have their opinions listened to and valued and to live in an environment where standards are monitored. Since the previous inspection processes for minimizing individual risk have been improved. EVIDENCE: At the present time the home continues to be managed by Mr. David Gilbert on a temporary basis, following the departure of the previous registered manager. Mr. Gilbert is also the Registered Manager of a neighbouring, local authority residential resource for adults with learning disabilities. It has been agreed with the Commission that Mr. Gilbert can manage 66 St Edmunds on a temporary basis without making an application to the Commission for registration. However, should this secondment extend past 01 October 2005, the Commission will expect Mr. Gilbert to make an application for registration. The home was able to evidence that systems are in place to monitor and evaluate the standards of care offered. Residents are consulted on issues 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 21 effecting the home and residents meetings are held on a regular basis. Monthly visits to the home by a representative of the owning organisation are carried out in compliance with Regulation 26 of the Care Homes Regulations 2001. Records, policies and procedures required by regulation were referred to throughout the inspection. A requirement made at the previous inspection for the introduction of a written admission procedure remains outstanding. Since the previous inspection, progress has been made in the introduction of detailed risk assessments for all residents. There is still an outstanding requirement for all staff to receive training in moving and handling but arrangements have been made to ensure that this is addressed by October 2005. 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 N/A 2 2 3 Standard No 22 23 ENVIRONMENT Score 1 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 2 3 2 3 3 Standard No 11 12 13 14 15 16 17 3 x 3 x 3 x 2 Standard No 31 32 33 34 35 36 Score x x 2 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 66 St Edmunds Road Score x x 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 2 x 2 x I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4&5 Requirement The Registered Persons must ensure that a Statement of Purpose and Service User Guide are produced and made avilable to all service users. This is a repeat requirement. The Registered Persons must ensure that the home has a written admission procedure which sets out the process for familiarising prospective service users to the environment provided at the home and other service users being accommodated. The Registered Persons must ensure that every resident is provided with a detailed plan of care which identifies how assessed care needs will be met. The Registered Persons must ensure that individual resident care plans are kept under review. The Registered Persons must ensure that a detailed risk assessment is completed for all residents who wish to manage their own finances. The Registered Persons must ensure that the home produces a Timescale for action Immediate 2. 2 14(1)(d) 15.08.05 3. 6 15(1) 15.08.05 4. 6 15(2)()b) Immediate 5. 9 13(4)(b) 15.08.05 6. 16(2)(i) 17 15.08.05 Page 24 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 7. 13(2) 20 8. 22 22 9. 16(2) 26 10. 23(2)(j) 26 planned menu of meals proviced to residents which evidences that they are provided with a varied and nutritious diet.This is a repeat requirement. The Registered Persons must ensure that the home maintains a record which provides an audit trail as to which staff have received training in the administration of intrusive medication, by whom and the content of such training. Evidence must also identify a person within the organisation who is responsible for ensuring that this training is received and holds ultimate responsibility for this practice. The Registered Persons must ensure that the home has a complaints procedure which is available to all residents, staff and visitors to the home. The procedure must include information as set out in Regulation 22 of the Care Homes Regulations 2001. The Registered Persons must provide a clear assessment of what benefits can be derived by the provision of vinyl flooring in individual residents rooms and a copy of this assessment submitted to the Commission for Social Care Inspection and included on the individual resident care plan.Otherwise all resident rooms must be provided with carpeting as the flooring of choice. This is a repeat requirement. The Registered Persons must ensure that all residents are provided with a wash handbasin. Where the installation of such a facility would pose a signficant risk to an individual resident, a I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Immediate Immediate 15.08.05 30.08.05 66 St Edmunds Road Version 1.40 Page 25 11. 16(2)c 28 12. 13(5) 32 detailed assessment of such risks must be carried out and a copy provided to the Commission for Social Care Inspection and included on the resident care plan. This is a repeat requirement. The Registered Person must 30.08.05 ensure that new covers are provided for the three-piece suite in the lounge or that the suite is replaced. The Registered Persons must 28.10.05 ensure that all staff working within the home receive training in Moving and Handling. This is a repeat requirement. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 30 Good Practice Recommendations The Registered Persons should provide all residents with a cleanable linen basket with lid for the purposes of transferring soiled laundry from their bedrooms to the laundry room. 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection 5th Floor St Vincent House Cutler Street Ipswich IP1 1UQ 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 66 St Edmunds Road I54 - I04 S37220 66 St Edmunds Rd V237626 050620 Stage 4.doc Version 1.40 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!