Inspection on 18/04/05 for 94 Chatsworth Road

This inspection was carried out on 18th April 2005.

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

94 Chatsworth Road 25/10/06

94 Chatsworth Road 30/09/05

94 Chatsworth Road 18/11/04

94 Chatsworth Road 21/05/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 94 Chatsworth Road Westfields Hereford Herefordshire HR4 9HZ Lead Inspector Jean Littler Announced Inspection 18 April 2005 10:00 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. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service 94 Chatsworth Road Address Westfields, Hereford, HR4 9HZ 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) 01432 340560 Aspire Living Ms C Jones PC 4 Category(ies) of Learning Disbaility (LD) 4 registration, with number of places 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions of Registration other than those referred to on the previous page. The Commission plans to negotiate with the providers about adding a Condition of Registration to reflext that some of the service users have a physical disability in addition to their learning disability. Date of last inspection 18th November 2004 Brief Description of the Service: 94 Chatsworth Road is a service run by Aspire Living and Choices Ltd. which is a Voluntary Organisation. The head office is based at the Fred Bulmer Centre, Wall Street, Hereford, HR4 9HP. The Care Home provides personal care, social support and accommodation for four adults with learning disabilities, some of whom also have physical disabilities. The accommodation is provided in a purpose built bungalow within a modern housing development in Hereford. There are pubs, local shops, a supermarket and post office all within a distance that residents can access. Transport for longer distances is provided in the Home’s unmarked minibus. The four single bedrooms have sinks fitted and there is a communal assisted bathroom, assisted shower room and in three toilets. The bedrooms are smaller then the standards recommend for wheelchair users. The total average living space provided exceeds the size set in the National Minimum Standards. The design of the building takes account of the access needs of wheelchair users, with wide corridors and door openings of 950mm. Opened in 1996 the premises met relevant building regulations at that time. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine announced inspection was carried out on a weekday morning between 10am and 1.30pm. The manager completed an inspection questionnaire following the visit to provide additional information. The providers monthly visit reports to the Commission and other communication with the Home since the last inspection were all considered as part of the assessment process. The inspection was arranged at short notice so no consultation took place with external professionals and resident’s relatives on this occasion. The inspector spent some time with them but they were not able to express their opinions of the service provided. The manager assisted with the inspection process and one support worker was interviewed. All four residents were present for some of the time before going to planned activities. What the service does well: What has improved since the last inspection? What they could do better: It would be beneficial for the residents if they had more personalised communication aides available to help them express themselves and the 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 6 agreed actions from their Person Centred Planning meetings were being followed up by their keyworkers and reviewed regularly. To help safeguard residents, staff recruitment processes need to be improved and the information about what the residents have to pay for should be made clearer. The way the Organisation monitors the quality of life for the residents needs to be further developed to ensure continual improvements are made. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 Information about the service is available in a format suitable for the residents’ representatives. This would be further improved if information about any extra charges was clarified. It may benefit future residents if the Service User Guide was also available in a format suitable for people with a learning disability. The Home is currently full but suitable assessment and admission procedures are in place should a vacancy occur. EVIDENCE: The Statement of Purpose and Service User’s Guide have been completed and given to all residents’ representatives. Currently the Guide is not available in a format suitable to people with a learning disability. The Terms and Conditions of Residency has also been finalised. Some representatives have yet to be asked to sign up to this document. The manager agreed to ensure that any additional fees charged to service users, for example vehicle costs, are made explicit before the documents are signed. The same four men remain in residence, however if a vacancy occur there is an assessment and admissions procedure that includes arrangements for visits and a trial stay. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 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) 6,7,8,9,10. The evidence seen indicated that the care planning system in place provide s staff with relevant information about residents’ assessed needs and how risks are to be reduced. Input from residents and their representatives is encouraged but this would be further improved by linking the residents’ Person Centred aims into the care plan goals and holding review meetings more regularly. EVIDENCE: All residents have care plan folders and a sample seen contained details about personal care and health needs, regular activities, personal preferences, management of risks e.g. for swimming. The daily reporting forms showed that these needs were being met. Records were being held securely and a policy is in place to guide staff about confidentiality of information. The residents cannot easily contribute to the care planning process due to their abilities but efforts have been made to involve them and their representatives through Person Centred Planning sessions. The agreed actions from these need to be included in the care plans and followed up. Reviews have been held but one care plan showed a gap between meetings of over nine months. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 11 Aspire’s Communications Facilitator has started work with one resident. Communication systems should be further developed to assist all residents with their understanding and to empower them to make more choices. Input from relatives and representatives is encouraged by keyworkers and they are invited to review meetings. It was positive that efforts are being made to find an advocate for one resident who does not have an external representative. The manager agreed to expand the care guidance about one personal care area that has caused some concern to the resident’s representative. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 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) 11,12,13,14,15,16. The evidence seen indicates that the residents are being given opportunities for personal development through daily living and planned activities. Links with the community, friends and family are actively promoted. Day care arrangements have been radically changed recently but positive efforts have been made to develop timetables of chosen pastimes. EVIDENCE: Day care funding has recently been withdrawn by the local authority so now only one service user attends one day centre session each week. Staff have made good efforts to access activities that residents will enjoy and will benefit them. e.g. Monday club, college or music sessions, swimming etc. One service user responds positively to fewer activities so staff are still trying to explore new options for him. His timetable did show trips out to the spa bath and shops as well as passing the time at Home with long baths and sensory time. All residents seemed relaxed and willing to go out on their planned outings. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 13 Service users are encouraged to socialise and one service user was supported to hold a big 30th birthday party at a large venue in Hereford. A short barge trip was also arranged for a birthday celebration. Several holiday options are being considered for the coming year. Under the current funding arrangements residents have to contribute towards holiday costs. The Home has a recreation budget however now that almost all day care is to be provided by the Home, the Organisation should consider reviewing this and giving some guidelines to the manager about what activities the Organisation will pay for as part of the Day Care service offered. Staff understand that residents have rights and the care practice reflects an appreciation of this e.g. daily routines are flexible depending on activities and resident’s health and frame of mind. Residents are encouraged to develop their self-help skills with staff support and all have some personal goals they are working towards. Residents’ relationships with their friends and relatives are encouraged and visitors are welcomed. A diary has been introduced to improve communication with one relative. One resident represents others on a consultation forum. He has also been part of the successful campaign to improve disabled access at the county swimming pools. It is positive that he has been supported in these arenas; he even has a signature stamp for signing letters and cheques. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 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) 18,19,20, The evidence seen indicates that suitable arrangements are in place to meet the personal and health care needs of residents in ways that they prefer. Some areas have been improved to better guide the staff in giving care and in moving and handling procedures. Some areas of medication management still need to be addressed to meet the standard. EVIDENCE: Service users were clean and well presented. The care plan sampled contained information about the resident’s preferred personal care routines. All personal care is given in private to promote their dignity. The residents’ health needs discussed were well understood by the manager and the staff, and health appointments were being prioritised. All health care interventions were being recorded in the care plan records and health is considered at each review. It is positive that annual health checks are being arranged and that tests had been pursued for one resident’s symptoms. Weights are being monitored every two months and a healthier diet menu has been introduced. The guidance for moving and handling procedures has now been approved by a trained assessor. Support from external professionals e.g. Occupational Therapist, had been requested appropriately for two residents. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 15 Accidents were being recorded and none had occurred recently that required A&E hospital treatment. Assessments are in place for pressure care and the use of bedrails. The medication records showed doses were being given as prescribed and records were being fully completed. A check of one type of tablet showed the correct balance was in stock. The manager is liaising with the pharmacist so any allergies are shown on the charts. Efforts to provide more in depth staff training continue. All staff have attended a short session and three have attended a college course. The three requirements relating to medication management have not been fully actioned so they have been brought forward and a new time frame set. A new and less intrusive emergency medication has been introduced for one service user. Staff training has been provided however when this was first needed the worker on duty followed the previous emergency routine and did not give the new medication. The manager needs to ensure staff are competent enough to follow the agreed procedure. The manager is still trying to get some protocols for emergency nursing interventions to be approved by the health specialist involved. Evidence that staff are given a choice about carrying out these procedures, and that residents or their representatives have given their consent should also be held. This is necessary to safeguard residents and staff. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 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 standard(s) 22,23. The evidence seen indicates that appropriate arrangements are in place for receiving and responding to complaints. Arrangements to provide protection to residents are in place that include staff training. Two areas have been identified that if improved will increase the protection offered to the residents. EVIDENCE: The complaints procedure is clear and is on display in the Home. A current complaint from a relative is being addressed in a pro-active manner with the objective input of appropriate external professionals. All staff have received Adult Protection training from the Local Authority and the worker spoken with said he would report any concern immediately. No concerns of this nature have been raised since the last inspection. The manager should keep evidence of consultation with external representatives over charges above those agreed in the Terms and Conditions of Residency to show transparency and protect residents’ financial interests. As detailed in the staffing section below, recruitment practices need to be made more robust to increase the protection offered to residents. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 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 standard(s) 24,25,26,27,28,29,30. The evidence indicated that the Home is suited to its current purpose and provides a comfortable and attractive environment. The majority of environmental risks to residents are being managed effectively, however two risk areas need to be addressed. The arrangements to maintain cleanliness and deal with repairs are working effectively. EVIDENCE: The home was clean, odour free, bright, comfortable and homely and it has been adapted for those with a physical disability. It has been recently improved by the kitchen and dining room being made open-plan. The Landlord reportedly deals promptly with repairs. The bedrooms are all single with sinks. A communal assisted bath and shower room are provided and three toilets. The bedrooms are smaller than the recommended size for the two wheelchair users, but there is additional communal space to compensate for this. The manager is aware that because the rooms are under sized for wheelchair users any future admissions of resident’s with mobility difficulties will need to be discussed with the Commission. All bedrooms have been nicely decorated and personalised e.g. with double beds, or sensory equipment. One resident has recently been provided with a new mattress. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 18 Efforts to provide a tracking hoist for one service user are being pursued following consultation with the Occupational Therapist. Hand washing facilities in the laundry room have been improved and a new washing machine supplied that has suitable infection control cycles. A recent Environmental Health inspection did not highlight any shortfalls. The risk management arrangements for Legionella and burns from hot pipes still need to be addressed. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,34,36. The evidence seen indicated that suitable staffing levels are being maintained by a team of trained and committed staff. Systems are in place to provide the team with clear direction and professional support. Recruitment practices within the Organisation currently fall below the standards required to protect the residents. EVIDENCE: There are no current staff vacancies and staff turnover has been low. The manager is aware that some vacancies are likely to occur in the near future. A sample of rotas were seen and these showed that three staff are working during the day with one sleeping in overnight. The staff compliment is for 357 hrs per week, and ten care staff are employed to cover the rota in a flexible manner. The interactions seen between the staff and residents during the visit were friendly and appropriate. The staffing levels have been stretched recently due to changes in the day care arrangements. The manager reported that staffing levels will need to be kept under review as the change has reduced the time available to staff for keywork duties and to the manager for administration. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 20 Staff have job descriptions and roles within the Home that include key working for residents. A senior supports the manager. It would be beneficial if the role of shift leader were clarified and lines of accountability shown on the rota when no senior staff are on duty. A member of staff spoken with reported that the regular staff meetings and supervision sessions were productive and that team morale was good. He had a positive attitude towards his role and had found the training he had attended very useful. This included moving and handling, fire awareness, basic first aid. It is positive that 40 of care staff have an NVA Award in Care and that LDAF is being introduced for new staff. The training available has been increased and now also included Dementia Awareness, Adult Protection, and Person Centred Planning. The current level of First Aid training does not meet the standard as this states that a Qualified First Aider should be on duty at all times. This level of cover should be provided unless a risk assessment shows that other adequate arrangments are in place. An additional inspection to assess recruitment processes within the Organisation was carried out at the Head Office on 20th April 2005 between 11am and 1pm. The sample of records seen showed that the Regulations had been breached as two satisfactory written references had not always been obtained prior to employment commencing. A separate report is available on request from the Commission detailing the requirements made. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 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 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) 37,38,39,40,41,42,43, The evidence indicated that the Home is running well and the manager is a competent leader who is supported by her team and by others within the Organisation. The Organisation has improved its management framework by developing policies and support for Health and Safety matters. The internal quality checking systems need to be further developed to ensure continual improvements in the service. EVIDENCE: Since the last inspection the manager has been working part time at another of the Organisation’s Homes, however because there is a senior and an experienced staff team the Home has continued to run smoothly. Her limited time at the Home has delayed her implementing some planned management improvements e.g. the new care plan format. She is now back on a full time basis and plans to move things forward quickly. It is positive that new office equipment has been provided to support these aims. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 22 Staff and other professionals have reported to the Commission that the manager is approachable and pro-active, and she clearly had a good rapport with the service users. She is currently working towards her NVQ4 in Care Award to update her professional knowledge. She should attend in depth medication training as she is responsible for managing the system. A lot of effort has gone into policy development within the Organisation over the last two years and nearly all the policies are now in place in line with the National Minimum Standards Appendix 3. The organisation now has a representative who takes the lead on Health and Safety matters. Risk assessments are in place for the use of bed rails. Fire drills and tests were being held at suitable intervals and the dangers from hot bath water controlled. Some hot pipes to radiators are exposed and this could be hazardous for service users. The requirement to complete a risk assessment for this and for the control of Legionella have been brought forward. The inspection check list showed evidence that regular servicing of equipment was taking place. The records required were being maintained. One resident’s cash tin and records were checked and this balanced against the records that showed appropriate expenditure. Insurance cover is in place and a finance officer supports the manager with budget management. There are some consultation processes in the Organisation and monitoring through monthly provider visits. A formal quality assurance system is being developed but has not yet been implemented. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 3 3 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 4 3 4 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score 3 x 3 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 94 Chatsworth Road Score 3 3 2 Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 3 2 3 Version 1.20 Page 24 E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc 21 x 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 25 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 YA20 Regulation 13 Requirement The Manager and staff must receive appropriate medication training in line with Standard 20, from an appropriately qualified source. -The management of medication storage keys must be made more secure and brought into line with the organisation’s policy. -Protocols for the administration of emergency medication need to be approved by the health specialists involved. (Previous time scale 31/1/05. Not fully actioned so brought forward). An effective Quality Assurance system must be developed and actioned. Results of reviews must be reported upon and circulated to participants, stakeholders and the Commission. (previous time scale 31/1/05. Not fully actioned so brought forward). A risk assessment must be completed for the risks associated with unprotected hot pipe work and carry out any E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Timescale for action 30/9/05 30/6/05 31/7/05 2. YA39 24 30/8/05 3. YA42 13 30/6/05 94 Chatsworth Road Version 1.20 Page 26 4. YA42 13 5. YA42 13 safety measures identified as needed. (Previous time scale 31/1/05. Not actioned so brought forward). A risk assessment regarding the control of Legionella in the Home must be carried out by a competent person. Any recommended control measures that are not already in place should be actioned. (Previous time scale 31/1/05. Not actioned so brought forward). A Risk Assessment regarding the need to provide a Qualified First Aider at all times, must be completed and forwarded to the Commission. Any additional staff training identified from the risk assessment must be completed by the end of 2005. 30/6/05 31/7/05 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 YA5 Good Practice Recommendations A representative for each resident should be asked to agree to the Terms and Conditions of Residency. Any additional fees charged to residents should be made explicit in the contractual agreements. Include actions agreed at the Person Centred Planning sessions in the care plan and followed up as goals. Hold care review meetings at least every six months. Expand the guidance for staff about the one personal care area that has caused some concern to the service user’s representative. 2. YA6 and 7 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 27 3. 4. YA7 YA23 Continue to develop communication systems appropriate to each resident. Develop a policy and keep evidence of consultation with external representatives over charges made above those agreed in the Terms and Conditions of Residency. Keep evidence that staff are given a choice about carying out emergency nursing interventions and that residents or their representatives have given their concent to these procedures. 5. YA20 6. 7. 8. 9. 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 28 Commission for Social Care Inspection Hereford Area Office, 178 Widemarsh Street, Hereford HR4 9HN 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 94 Chatsworth Road E52 E02 S24688 Chatworth Road V221335 180405 Stage 4.doc Version 1.20 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!