Inspection on 25/04/07 for 72a Broad Street House 2

This inspection was carried out on 25th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

72a Broad Street House 2 05/05/09

72a Broad Street House 2 04/05/06

72a Broad Street House 2 19/01/06

72a Broad Street House 2 06/06/05

72a Broad Street House 2 08/02/05

72a Broad Street House 2 16/09/04

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 72a Broad Street House 2 Cedar And Douglas Units 72a Broad Street Clifton Shefford Bedfordshire SG17 5RP Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 25th April 2007 06:10 72a Broad Street House 2 DS0000014885.V339708.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 72a Broad Street House 2 DS0000014885.V339708.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. 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 72a Broad Street House 2 Address 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) Cedar And Douglas Units 72a Broad Street Clifton Shefford Bedfordshire SG17 5RP 01462 813824 01462 813824 Kathryn.chainey@hft.org.uk www.hft.org.uk Home Farm Trust Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th May 2006 Brief Description of the Service: Cedar and Douglas was one of two homes run by the Home Farm Trust in the small town of Clifton. The building was divided into two units to support 8 adults with learning disabilities; the units catered for 8 service users with complex needs and autism. The units were designed to accommodate four service users independently from the other unit. As a result of this, each unit had its own kitchen, lounge, and bathing facilities and was linked by the laundry room on the ground floor and the staff room on the top floor. There were separate entrances to each unit and service users communally shared the garden facilities. The home was situated close to local amenities including shops and pubs. The service users were able to access other towns such as Bedford, Biggleswade, and Shefford with the use of their local transport or route cars and the homes own transport facilities. 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 25/04/07 over 2 ½ hours by Pursotamraj Hirekar. The new manager coordinated the inspection. The method of inspection included study of care plans, risk assessments, personnel records, staff deployment duty rota, relevant care delivery documents, discussions with manager and staff, conversation with service users’ and partial tour of the building. The pre-inspection service users’ survey information was included for analysis and preparation of this report as well. What the service does well: What has improved since the last inspection? What they could do better: The home must complete updating care plans of all service users. The home must evidence that all the staff employed including agency staff have relevant qualification, skills and experience for the tasks they are expected to do. The home must evidence that all the staff employed including agency staff have relevant qualification, skills and experience for the tasks they are expected to do. The home must ensure that all the staff records are at all times available for inspection. The home must ensure all staff employed including agency staff receive appropriate training. 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 6 Arrangements must be made to ensure all staff including agency staff receives regular supervision. 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. 72a Broad Street House 2 DS0000014885.V339708.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 72a Broad Street House 2 DS0000014885.V339708.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area was good. This judgement was made using available evidence including a visit to this service. Information about the home was always readily accessible and there was enough information telling prospective service users how to access it, which enabled them from making an informed choice about the home and living there. EVIDENCE: No new service users had been admitted since the last inspection. Therefore this standard could not be fully assessed. However there was evidence included within the records of the service users whose lives were tracked, which supported that the home had undertaken a full assessment of needs for each of them. The needs assessment was also supported by a health and social services assessment. The home had developed a service user care plan from the assessment of needs. The commission had carried out a service users’ survey prior to this inspection, to get the feedback from the service users’ and their family members about the services they receive at the home. 6 service users’ have responded to the survey. 5 of them have said that they had the opportunity to make an informed decision with the help of their family members and social workers. Some quotes from the service users’ survey in their own words: 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 9 Service user –1 said ‘was happy to move into Douglas House, and was welcomed by staff and other residents and has remained happy for 2 years. ‘We met on four occasions to talk to staff and have a look around the house and garden’. Service user – 2 said ‘had a staged visit’s stayed for tea Tiffin tea overnight then for weekends until she was happy and decided to move when she was comfortable’. Service user – 3 said ‘I don’t think he was counselled about moving to Cedar House from Herald House – I was not and was against the idea at the time – some years ago (Mum). 72a Broad Street House 2 DS0000014885.V339708.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area was adequate. This judgement was made using available evidence including a visit to this service. Service user plans contained satisfactory information, however further development was needed to ensure both the plans, and risk assessments were reviewed and updated at regular intervals. EVIDENCE: Currently, the home had 7 service users’ living. The assessments of the all the 7 service users’ were completed. 2 service users’ comprehensive care plans were completed and 5 service users care plans were at different stages of completion. The manager informed the inspector that updating all the care plans would be completed before the end of May 2007. Service user – 1 on the basis of risk assessments reviewed on 26/02/07 and 23/04/07, care plan reviewed on the 03/03/07, and 23/04/07 comprehensive care plan was developed. The care plan covered aspects such as personal profile, communication profile, and behaviour profile, support needed to plan, make decisions and give consent, health needs that include – dental care, sight, hearing, mobility, medical condition, continence, medication, syndrome, nutrition, vaccination, mental health, foot care, skin, allergies, adverse 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 11 reaction to medication, exercise, known risks and medical contacts. The support needed with personal care, support needed with looking after their home and tenancy, support needed with employment, college and day services, contact details of family members, support needed to make and maintain friendship and relationships, support needed to maintain cultural aspects of life, support needed with leisure / hobbies, support needed with managing money and dealing with paper work. Service user, team manager and key worker were involved in the preparation of the care plan. Service user – 2-care plan review was carried out on the 08/12/06. Service user, parents, key worker, assistant service manager, and service manager participated. The review discussed outstanding actions from last meeting, accommodation, daily activities and leisure, college, friends and family, health, and actions agreed. The inspector was informed on this inspection that next care plan review is scheduled in April 2007 following which the care plan will be updated before the end of May 2007. Service user – 3-care plan review was carried out on the 07/03/07. Service user, team manager, assistant service manager, mother, key worker, and resource centre manager participated. The review discussed outstanding actions from last meeting, accommodation, daily activities and leisure, college, friends and family, health, finance, risk assessments, other issues and actions agreed. The comprehensive updated care plan was scheduled completion before end May 2007, the manager informed the inspector. All the 6 service users’ who replied to the commission’s survey have said that always they make decisions about what they do each day during the day evening and at weekend. The above response from the service users’ indicate that the home was providing necessary support to enable service users’ lead independent life style. Some quotes from the service users’ survey in their own words: Service user – 1 said ‘has a choice in most things he does, he sometimes says no then changes his mind, when he gets to a place he starts to enjoy himself’. Service user –2 said ‘yes within the limitations of staffing’. 72a Broad Street House 2 DS0000014885.V339708.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area was good. This judgement was made using available evidence including a visit to this service. Service users were offered a healthy diet and were supported to access various activities and day care opportunities that enabled them to achieve quality of life goals. EVIDENCE: The menu’s choices were in a suitable format for service users to make an informed choice and decide what they would like to eat. The home in consultation with the service user had detailed various activities for the service user which included employment, college, day services, support needed to make and maintain friendships and relationships, including cultural aspects of life. The planned service users’ activities were compared with today’s actual situation and found that all the service users’ were engaged as planned for the day. Service user – 1 accesses college 4 days a week, 1 day a week based at the home completing household tasks, shopping and relaxing. The home had made appropriate arrangements for the service user to contact and visit family. The other leisure activities service user was engaged in include; spending time with 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 13 friends, swimming, bowling, cinema, pub, singing, walking, shopping and holidays. Service user – 2 attends the resource centre more often recently, she particularly enjoys the needlework group. She will do some colouring and has enjoyed using the computer. Attends college on a Tuesday and Wednesday. Incidents are reported when relief or agency supports her and the home would tend not to offer college if there were no core staff available. She enjoyed her visits to her parent’s home and likes to see her brother. The home had made appropriate arrangements for the service user to have good relations with the family. Service user – 3 the home had made appropriate arrangements for daily activities that meet the assessed needs of the service user, which include, varied programme of weekly activities – with 2 ½ days each at college and number of sessions at the resource centre. The service user enjoys going to college and benefits from the social and integration opportunities available. In the leisure time the service user enjoys taking part in a wide range of social and recreational activities both at home and within the local community. Relationship with family and friends are maintained that help achieve quality of life goals. 72a Broad Street House 2 DS0000014885.V339708.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area was good. This judgement was made using available evidence including a visit to this service. The systems for the administration of medication were satisfactory. The service users’ receive support to meet their assessed individual physical and emotional needs. EVIDENCE: The home had made arrangements for the personal and healthcare support of the service users’. Service user – 1 attends dental clinic every 6 months, attend optician when required, attend health centre appointments annually, staff administer medication, staff support around his rituals he tends to carry out due to his autism, staff support to choose and plan healthy menus, staff support to plan and attend appointments regarding depression and psychosis, chiropodists visits every 6 weeks, and known risks. The staffs provide support to follow guidelines for morning and evening routines with personal care. Service user – 2 appointments with health care professionals were managed by the home regularly. The staff monitors continence at night, bowel movements, and diet. 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 15 Service user – 3 appointments with health care professionals were managed by the home regularly. Medication was carried out as prescribed. 72a Broad Street House 2 DS0000014885.V339708.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23 Quality in this outcome area was good. This judgement was made using available evidence including a visit to this service. The arrangements for protecting service users were satisfactory. EVIDENCE: The home had a complaints policy and procedures. The home had made arrangements to ensure the service users money is properly managed. 2 staff members now sign all money transactions record relating to service users and a new security number is put on file tag for safety. Of the 6 service users’ those who responded to the survey, 4 of which have said that they know who to speak to when they are not happy and 2 said no. Some quotes from the survey as said by the service users: Service user – 1 said ‘has once (that I know of) approached a staff member when unhappy however, he is easy going and I’m therefore unsure whether or not he would always do so – he really needs someone to watch out for him’. Service user – 2 said ‘will always look for a member of staff if unhappy’. Service user – 3 said ‘my disability is such that my change of behaviour is the only means of staff being aware I am unhappy and it is not easy to route out the problem’. 72a Broad Street House 2 DS0000014885.V339708.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 &30 Quality in this outcome area was good. This judgement was made using available evidence including a visit to this service. The standard of the environment within this home was good, providing service users with an attractive and homely place to live in which suited their needs. EVIDENCE: The home provided a purpose built, comfortable environment for service users, which was free from offensive odours with cheerful and well-maintained decoration and furnishings. The home was close to local amenities and transport if required. All rooms were single occupancy with en suite provision. Service users spoken to were clearly happy with their individual bedrooms and they had free access to them and were encouraged to take responsibility to maintain their cleanliness. Toilets and bathrooms were safe and suitable for their intended purpose and were in appropriate locations. The home had maintained monthly record of health and safety checks of rooms, toilets, bathroom, dinning, kitchen, hallway, lounge, cupboard, landing and fridge, freezer and water temperatures, and then requests made with description of fault if any for their maintenance. 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 18 There was mixed response from the service users’ to the survey for the questions on ‘is the home fresh and clean’. 3 services users’ said the home is always fresh and clean where as 3 service users have said sometimes. Some quotes in the words of the service users regarding the cleanliness: Service user – 1 said ‘nice, new floor in dinning room’. Service user – 2 said ‘the house is always clean and tidy, the kitchen is the place where people meet, toilets are spotless’. 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area was adequate. This judgement was made using available evidence including a visit to this service. The staff and the service users had enjoyed good working relationship and benefited from wellsupported and supervised staff. However, the home need to provide all the relevant documents on inspection with regard to staffs statutory checks and evidence supervision and training of agency staff. EVIDENCE: On this inspection staffs’ supervision record and planning sheet was seen and found that staff supervision was carried out once in every 2 months. Staff supervision carried out as scheduled benefited service users’ from wellsupported and supervised staff. The home had deployed 3 agency staff and there was no information provided on this inspection with regard to agency staffs’ supervision. This is an area of concern that needs to be sorted out in the best interest of the service users. For example 1 service user as part of her daily activities attends college on a Tuesday and Wednesday. Incidents are reported when relief or agency supports her and the home would tend not to offer college if there were no core staff available. Staff training needs assessment was carried out and a month wise training plan for the staff (agency staff not included) was presented; the areas of 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 20 training covered food hygiene, first aid, health and safety, moving & handling, induction, POVA, PCP, think positive, and autism. Staffing level numbers within the home were maintained to meet the appropriate ratio based upon the needs of the service user, by regular use of agency staff. The 3 agency staff deployed by the home, the manager was able to provide the details of only 1 agency staff which covered CRB number, work permit number and training received in moving & handling, food & hygiene and first aid. There was no further information on when these training were received or any plans for future training that help achieve the assessed needs of the service users’. Further, there was no information provided on this inspection about the 2 more agency staff on their background, knowledge, and skills, which is another area for the home to address on priority. The manager had informed the inspector that the staff records such as CRB, references were kept at head office. There were mixed responses from the service users’ to the survey for the questions, do the staff treat you well, 4 service users’ said yes always and 2 service users said usually. When asked, do the carers listen and act on what you say, 2 service users have said yes always, 2 service users have said usually and 1 said sometime. Some quotes in the words of service users: Service user – 1 said ‘as far as we can ascertain. He is generally very happy and relaxed. When we were concerned by a change in his behaviour earlier in the year our concerns were rapidly addressed and he has been relaxed and happy since then’. Service user – 2 said ‘ the staff have always treated well and always welcome us when we visit offering tea’. When I ring the house to ask about something they will answer straight away or ask me to ring later so they can ask someone else’ (mother). 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area was good. This judgement was made using available evidence including a visit to this service. The manager with the help of the staffs made adequate progress in compliance of requirements from the previous inspection and established good working relationships with the staffs, service users’, and relevant professionals. However, all the targets planned for the year 2007 need to be actioned on time. EVIDENCE: The management had appointed a new manager, who reported to duty on the 01/01/2007. The manager was observed to communicate effectively with both service users, staff and appeared approachable. Service users and staff who were spoken to supported this view. The home had an inclusive atmosphere. The management had developed and introduced a new set of internal monitoring tools. These tools are designed to be used by the staff on all the shifts, which were comprehensive that covered areas of personal care, daily activities, medication, appoints with professionals including health. Water 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 22 temperature record checks were seen on this inspection and found the temperatures recorded were with in the safety limits. Developing and maintaining an effective quality assurance system within the home, was set as a requirement at the last inspection. Quality audit was carried out and action plan was updated on 21/02/07. The action plan covered areas such as service users meetings, service user reviews, and staff supervision, support and care plans, staff files, staff training programme, medication file, risk assessments, new daily log sheets, specific needs of service users, Coshh, workstation for staff team, staff rotas, allocation of duties, service users finances, library, relief staff, home environment, accidents/incidents records, waking night routine, office locked cupboard, inhouse staff responsibilities, and training files. Each area covered in the action plan had identified the needs, action to be taken, person responsible, target date, and date achieved. Most of the target dates have been met with very little short fall in the area of support and care plans update, risk assessments, and recruitment of new staff. This new internal monitoring system was simple and specific that help support improvements and benefit service users’ achieve quality of life goals. 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 2 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 3 3 3 X 3 X 3 X X 3 X 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 24 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 YA6 Regulation 15 (1) (2)(a, b, c, d) 18 (1) (a) Requirement The home must complete updating care plans of all service users. (Previous requirement part met) The home must evidence that all the staff employed including agency staff have relevant qualification, skills and experience for the tasks they are expected to do. The home must ensure that all the staffs’ records are at all times available for inspection. The home must ensure all staffs employed including agency staff receive appropriate training. Arrangements must be made to ensure all staff including agency staff receives regular supervision. Timescale for action 31/05/07 2. YA32 31/05/07 3. 4. 5. YA34 YA35 YA36 17 (3) 18 (1) (c) 18 (2) 31/05/07 30/06/07 31/05/07 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 72a Broad Street House 2 DS0000014885.V339708.R01.S.doc Version 5.2 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!