Inspection on 15/05/07 for Albert House

This inspection was carried out on 15th May 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Albert House 13/02/09

Albert House 07/04/08

Albert House 09/05/06

Albert House 03/11/05

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 Albert House 167 High Street Clapham Bedfordshire MK41 6AH Lead Inspector Katrina Derbyshire Unannounced Inspection 15th May 2007 15:10 Albert House DS0000065423.V337026.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 Albert House DS0000065423.V337026.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. Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Albert House Address 167 High Street Clapham Bedfordshire MK41 6AH 01707 652053 01707 662719 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) CareTech Community Services (No.2) Ltd Donna Maria Lee Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of people that can be accommodated at the home is 8. The home shall only admit service users between the ages of 18 and 65 years. All persons who are admitted to the home must have learning disabilities as their primary assessed need. The home may admit service users who have physical disabilities in addition to their learning disabilities. 9th May 2006 Date of last inspection Brief Description of the Service: Albert House is located in the village of Clapham, a short car or bus ride away from Bedford, which has shops, leisure facilities and links with national bus and rail services. The home has been converted from its original purpose as a domestic dwelling. The building is an extended bungalow which provides single room accommodation for 8 younger people with learning disabilities and who may also have physical disabilities. A communal lounge/diner and a room that is used for activities are located to the rear of the property. A shared drive at the front of the property leads to a parking area for several vehicles. To the rear of the property is a large garden that leads directly to the river Ouse. The Home manager provided the following information on charges in April 2007. The fees for this home vary from £938.00, to £1500.00 per week, depending on the assessed need of the person. Additional charges are made for hairdressing, aromatherapy, chiropody, toiletries, community based activities, holidays and transport other than for attendance at health appointments. Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was to undertake a key inspection. This unannounced inspection was carried out on 15th May 2007. During the inspection several areas of the home were visited and the inspector spent time with many of the people who live at the home in the sitting room. The care of two people was examined by looking at their records, observation and interviewing staff that look after them. The views of the relatives of people living at the home were also received through 6 returned comment cards and their feedback has been used alongside information from the home, through written evidence in the form of a pre inspection questionnaire to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. Observations of care practice and communication between the people living at the home and staff was also made at the inspection. The focus of this inspection was to look at the key standards and to follow up on previous requirements. What the service does well: Some of the things that are done well include: Before someone moves into the home staff carry out an assessment of their needs. The information that they gather is of a good standard and they make sure they find out the individual likes and dislikes of the person. This means staff will know how they should be supporting the person if they decide to move into the home. The manager is also very careful when they employ new staff that they make sure that they check where they last worked, and carry out another check against a special register that helps them make a decision if that person is suitable to work with vulnerable people. This means that people can feel safe knowing that the manager is cautious about whom they employ in the home, and that they do take their responsibilities in the recruitment of staff seriously. People also benefit from the way staff organise access to healthcare services. They have built up good working relationships with Doctors and Nurses, and call upon them very quickly when a person needs their help. This means people receive health care in a way that makes sure they receive medical attention that promotes their overall health. Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The cooker used to heat and cook food at the home was dangerous when we visited. There was no door handle to the oven door and the oven door was broken and there was no seal. This means that the food was not being heated to a safe temperature and staff were at risk of burning themselves. A notice was left at the visit that said a new cooker must be bought straight away, because this was a serious concern. The home still uses a high level of agency staff. Staff that work at the home permanently do feel that this impacts on the care of people at the home as they feel that they do not know as much about their needs. On the day of this visit a person that needs to wear a splint to help then to walk had, had it put on the wrong leg. No one noticed until much later in the day when someone that is employed at the home realised what had happened. This could have caused the person great discomfort. If someone living at the home needs to have their haircut, then this should be carried out in accordance with their individual needs and wishes. Staff had been cutting peoples hair; minutes of a meeting had described one person’s haircut as ‘totally unacceptable’. This practice is very outdated and needs to change straight away. People must experience and have access to opportunities available to anyone living in the community. Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 7 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. Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 People who use this service experience Adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Pre admission information on the home is not always sufficient to ensure people have accurate information to make an informed choice as to whether to move into the home or not, or know the services that are offered. EVIDENCE: The Inspector was shown a copy of the statement of purpose that was kept in the office. On examination of the records it showed that the statement of purpose was out of date, information relating to the manager for example stated that they were not yet registered as the manager. At the previous inspection in May 2006 it was reported that the manager had confirmed that work was being undertaken to review the guide, to ensure that it covered all required areas and would be produced in a format appropriate for the people living at the home. The manager subsequently submitted a further guide to the Commission for Social Care Inspection that did use pictures and had up to date information advising that this document had already been written, however this was not the copy shown at the inspection. The copy given by staff and as indicated by them as being the one in use did not meet this standard. Pre admission assessments were also noted to be in place. These documents had been completed prior to the person moving into the home. They gave a Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 10 detailed description on the needs of the person and included their personal likes and dislikes. In addition supplementary information was also seen, this had been provided by the placing authority and showed the assessment of needs as carried out by the relevant Social services Department. Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Care planning provides information to staff on the assessed needs of the people living at the home. EVIDENCE: Care plans were detailed and written on individual sheets for each assessed need. One person for example needed assistance in relation to the management of their epilepsy. This was detailed within their plan of care. Guidance to staff showed what they should do and the support that they should offer this person concerning their daily life, accessing medical assistance and providing emotional support. Through discussion with staff they showed a good level of knowledge of the content of the care plans, demonstrating that these documents were used by the staff team to ensure consistency in the care offered. Information from four out of the six returned comment cards from relatives of the people living at the home indicated that Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 12 they are satisfied with the care provided by the staff at the home. Again as reported by the manager at the previous inspection in May 2006, plans were supposed to have been in place to introduce person centred planning at that time. A staff member had recently attended training in this area just prior to this visit, a year later. It was noted that one person living at the home was having their plans changed to this approach to date and a revised method of reporting had been implemented. Records examined within the individual care files showed that people were receiving regular ‘talk time’. This showed that the person spent time on a one to one basis with their key worker to ascertain what they would like to do in their lives. Examples of choices included, relationships that the person wished to maintain or develop, clothing and the colour to paint their bedroom. Documentary evidence was also seen to show plans had been devised in consultation with appropriate health care specialists, particularly in relation to Twinwoods. Risks to people were discussed as part of their care planning review; these documents showed that the person, staff and a representative were given the opportunity to review the care services at the home and for the person to be involved in planning their care. If it had been identified that the person needed encouragement and support with independence this was documented. One person at this visit was seen to assist with the preparation and of the evening meal. Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Staffing shortages have resulted in an inconsistent level of activities being available to the people at the home. EVIDENCE: Staff and written information supplied by the manager confirmed that a choice of meals was available over the week and described a varied diet being offered. The evening meal on the day of this inspection consisted of sausages, mashed potatoes and two vegetables alongside a pudding. Staff also informed the inspector that people who lived at the home were now involved in setting the menus, a recently developed album with pictures of food types was being used to ask people what they would like. It was observed that one person did not want the meal that they were offered, the senior person on duty then asked if they wanted something else and came back with a replacement meal that was then eaten. The kitchen was seen to be clean and tidy. Although an Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 14 issue regarding the safety of the cooker is addressed within the management and administration section of this report. Documents examined within the individual care records showed that people maintained contact with their family; they could visit family members at their own home or be visited themselves. A prompt was in place that showed when a person needed assistance to send a birthday card to someone they felt close to for example. All the six returned comment cards confirmed that staff assisted their relative in maintaining contact with them. The staff on duty at the time of the site visit advised that none of the people were engaged in paid employment at this time. Entries made within the records supplied by the manager to the Commission for Social Care Inspection described the social and leisure activities the people had received. The information supplied indicated that activities that had been provided for example were shopping trips, walks and going out for a pub meal/drink. However staff confirmed that due to staffing shortages recently the level of activities especially relating to leaving the home had been reduced. An extract from minutes dated 29/12/06 stated, ‘it was felt that the lead up to xmas was poor, i.e. not being able to do some of the xmas activities due to staffing levels, i.e. carol service etc’. The room used mainly for activities in the home, was seen to be used mainly as a storage area at this visit. One staff member when interviewed said, “ We acknowledge that things need to get better, but hopefully with employing more drivers things will now improve”. As reported at the inspection in May 2006 this area was raised as a concern at that time. Information following this visit from the manager indicates that more recently there has been an improvement in this area. The care records seen also identified very different individual interests of the people and they were specific in the identification of the persons preferred leisure interests, regular contact with family members and visits to their homes were also included. Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Changes in the medication systems now ensure people receive their medication as prescribed, however the inconsistent support offered to people in meeting their personal care does not meet their individual needs, rights and choices at all times. EVIDENCE: Observation of the support including assistance with personal care was made during this visit. There was a difference in the support offered by the staff employed at the home and those from an agency. It was noted that when staff employed at the home provided support to people, they addressed them in a courteous manner, communicated with them throughout and sought feedback from the person. However the inspector was based in the lounge area of the home for a 43-minute period. Throughout this time people working at the home through an agency had limited communication with the people living at the home, one did not speak at all during this time even when they assisted someone to the toilet. It was also reported that another person that had Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 16 worked at the home through an agency had fitted a splint on a person that morning, this was on the wrong leg. It was a member of the housekeeping team that noticed this later on. In addition minutes of a staff meeting dated 02/02/07 under the heading of cutting clients hair said, ‘ This must now only be done by’ and then named 5 staff members and then continued ‘this was due to the latest hair cutting session and 1 clients haircut was totally unacceptable’. Healthcare plans were seen within the care records examined. These documents showed that the person had received access to a variety of healthcare professionals to meet their healthcare needs. Records and staff confirmed that people had attended opticians, chiropody and clinics when needed. Medication records were examined. The home used a monitored dosage system supplied by Boots. The medication administration records seen at this visit all contained initials of staff to show when medication had been given. Staff advised that the Deputy manager now had overall responsibility of ordering and returning any unused medication. This they felt had improved the medication systems in the home, as previously reported in May 2006 and from a returned comment card and from a recent regulation 26 visit there had been errors prior to this. Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The complaints system is good so people are able to raise concerns easily if they want to. EVIDENCE: The complaints procedure for the home was examined. This was written in simple terms ensuring that it was easy to understand how you could complain. In addition a document was also seen that used both words and pictures to help a person understand how they could complain. No complaints had been received by the home since 2005; therefore an assessment of their response to a concern or complaint could not be made. Returned comment cards indicated that family members were aware of their right to complain. Information supplied by the home as part of the pre inspection paperwork detailed that staff had undertaken training in abuse. Staff were aware of the homes policy in this area and stated that they would raise any concerns that they had immediately. No referrals have been made by this service at the time of this visit under the local protection of vulnerable adults guidance. Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The building is mostly suitable to meet people’s needs as the manager and staff strive to improve the environment, however further redecoration is still needed to ensure all areas are homely for the people at the home to live in. EVIDENCE: Accommodation was provided in an extended bungalow; therefore all accommodation is at ground floor level. Staff at the home had strived to make improvements to the standard of décor and furnishings in the home. One staff member advised the inspector of recent changes to the layout of the sitting room. Chairs had been moved towards the window to make use of the natural light and mobiles had been hung around this area. The carpet in the lounge had several small stains. Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 19 One person’s room had recently been decorated and it was reported that they were “delighted with the results”. Documents were seen within their care file to show that they had chosen the colour and theme for this. However other areas of the home also require redecoration, other people’s bedrooms were not of this standard. It was noted that the manager at the home sent repeated requests for this to be undertaken, but this was not always sanctioned. A request first made in over 2 years ago to have fencing placed at the lower end of the garden had still not been done. Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 20 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 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The systems in place for the recruitment of staff and vetting of prospective employees are robust and of a good standard and protect people. EVIDENCE: Examination of two staff files was undertaken to look at recruitment practices. It was noted that the files contained proof of identity; verification of employment history and that Criminal Records Bureau clearance had been obtained. The system that had been followed was extensive when recruiting staff. Responses had been recorded when people had been interviewed and these documents had also been kept. Job descriptions, person specifications and initial enquiry letters were also maintained on the personal file. Information regarding training of staff submitted by the home show that staff had undertaken training in areas including health and safety. Through discussions with staff it was confirmed that they had undertaken a variety of courses including those specifically to better understand the needs of the Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 21 people living at the home. One person interviewed who had worked at the home for just over 6 months said, “The training has been excellent”. In addition staff confirmed that they received regular supervision sessions with the management at the home. Staff stated that during this time they are able to review their individual work performance and can then with the support of management agree on actions to be taken to improve in their performance, which in turn improves the standard of care within the home. Observation of interaction between staff actually employed by the service and people living at the home showed that a good amount of communication took place between them including the use of non-verbal communication. The use of a high level of agency continues, this was also reported in May 2006. The effect of this has been addressed within the personal and healthcare support section of this report. Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 22 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 & 43 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Health and safety systems in this home are sufficient to provide an environment for people that reduce the risks associated with this area. EVIDENCE: It is acknowledged that the manager had repeatedly requested to have the cooker at the home replaced. During this visit the cooker was being used to prepare the evening meal for the people living at the home. The temperature in the kitchen during this time was noted to be higher than expected from just the use of an oven. The door to the oven had no handle. Staff demonstrated how they had to open this, through sticking their hand at the top of the door and pulling. The door had also broken with the glass panel having separated Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 23 from the rear guard. The seal on the oven door was broken. Staff and records confirmed that food cooked was of an unequal temperature. For example a pie that had been heated had varying temperatures to each side. One temperature taken did not reach the required temperature for food safety and could not be given to the people living at the home. An immediate requirement was made. It was noted that only due to the diligence of staff regarding the serving of food at a safe temperature, that an issue to date had not arose with the meals served at the home. Staff reported that they found the manager to be supportive. Staff felt that the home was improving under the guidance of the manager and deputy manager. The home seeks the views of people living at the home at meetings and encourages the involvement of advocates. Staff and training records showed that they had undertaken training relating to health and safety matters, including fire safety and food hygiene. Fire safety checks were undertaken alongside food temperature checks and records of these were seen. Risk assessments had also been undertaken and gave clear guidance to staff in how they could reduce the level of risk. Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 24 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 2 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 2 3 X 3 X 3 X X X 1 Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO none were made. 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 YA1 Regulation 4&5 Requirement Timescale for action 31/08/07 2. YA6 15 3. YA7 13(7) 4. YA12 YA13 16 A statement of purpose and service user guide containing all matters detailed in the relevant regulations, must be made available in a format suitable to all people in the home and prospective people so that they know what services the home can and will provide. All people living at the home 31/08/07 must have person centred planning to make sure that they are involved and guide the way they receive support from staff through this best practice method. There must be multi agency 15/06/07 agreement if a restriction is in place through the use of a stair gate. The reasons must be documented, to ensure a person is not subject to unsuitable restraint. Activities must be provided that 15/08/07 consistently meet the individual interests of the people at the home. Through sufficient staffing and arrangements of the designated recreational space in the home. DS0000065423.V337026.R01.S.doc Version 5.2 Albert House Page 26 5. YA18 18(1)(b) 6. YA18 12(4)(a) 7. YA19 12(1)(a) 8. YA24 23 9. YA42 12(1)(a), 13 (2) & 13(4) People must receive continuity of care from temporary workers at the home, so that their individual needs are met. People must have access to a range of community hairdressing services to meet their individual needs. The practice of haircutting sessions must cease. Arrangements must be in place to ensure people are supported when they require assistance from an aid, so that it is fitted correctly and does not cause discomfort to the person. Re decoration of the accommodation described within the report and the removal of the stains from the living room carpet must be done to create a homely environment for the people living at the home. A cooker must be available in the home that does not place people living at the home and staff at risk of burns and discomfort, and that is sufficient to heat/cook food to the required temperature. (Immediate requirement made) 30/06/07 15/06/07 15/06/07 30/09/07 22/05/07 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 Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 27 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 Albert House DS0000065423.V337026.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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