Inspection on 31/10/06 for Alder House Cheshire Home

This inspection was carried out on 31st October 2006.

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

Alder House Cheshire Home 07/10/08

Alder House Cheshire Home 03/03/06

Alder House Cheshire Home 09/06/05

Alder House Cheshire Home 13/01/05

Alder House Cheshire Home 27/05/04

Similar services:

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Dolphin Court

Fen Road

Wakes Hall

165 Putnoe Lane

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

CARE HOME ADULTS 18-65 Alder House Cheshire Home Lambourne Road Chigwell Essex IG7 6HH Lead Inspector Brian Bailey Unannounced Inspection 31st October 2006 9:45 Alder House Cheshire Home DS0000017981.V317552.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 Alder House Cheshire Home DS0000017981.V317552.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. Alder House Cheshire Home DS0000017981.V317552.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alder House Cheshire Home Address Lambourne Road Chigwell Essex IG7 6HH 020 8500 8491 020 8500 4660 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) www.leonard-cheshire.org.uk Leonard Cheshire Mr Dilip Kumar Mahadeo Care Home 19 Category(ies) of Physical disability (19) registration, with number of places Alder House Cheshire Home DS0000017981.V317552.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, under the age of 65 years, who require care by reason of physical disability (not to exceed 19 persons) On completion of the final phases of development a building regulation certificate must be sent to the Commission 3rd March 2006 Date of last inspection Brief Description of the Service: Alder House is a care home registered to provide care and accommodation to fifteen people with physical and sensory disabilities. The home is part of the Leonard Cheshire Foundation and Mr Dilep Mahadeo is the Registered Manager. Alder House is a purpose built single storey building set in spacious gardens incorporating a large lake, situated in a semi rural area of Chigwell, Essex on the border of London. All bedrooms are for single occupancy and adapted for wheelchair users and have en-suite toilet and bathroom facilities. The grounds are private, well maintained and accessible to wheelchair users. Each room opens out onto its own individual garden and patio area with garden seating A bus route provides access to the home, although the bus stop is approximately 10 minutes away by foot. There is a local train station and Woodford station is approximately 30 minutes away. Car parking facilities are available at the front of the house. As at 31st October 2006, the manager advised that the fees for accommodation ranged from £750.00 to £830.00 per week. Items considered to be extra to the fees include private chiropody, hairdressing, toiletries and newspapers. CSCI inspection reports are available from the home and the CSCI website. Alder House Cheshire Home DS0000017981.V317552.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection of Alder House was carried out on 31/10/2006. This report is based on a range of information that has been accumulated from our inspection records, site visits to the home, discussions and observations with residents, staff and the manager, questionnaires issued by CSCI and records kept at the home. The manager was on duty with the head of care and supporting staff. This report refers to the service users as residents, as this was stated by the manager as being the preferred term of address expressed by the residents at Alder House. Thirty standards were assessed, of these nineteen were met, ten were partly met and one not met. What the service does well: What has improved since the last inspection? The home continues to provide opportunities for residents to take part in activities of their choice both within the home and in the community. A new extension and an extensive refurbishment programme completed during 2006 have improved the facilities available for all residents. Alder House Cheshire Home DS0000017981.V317552.R01.S.doc Version 5.2 Page 6 What they could do better: 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. Alder House Cheshire Home DS0000017981.V317552.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 Alder House Cheshire Home DS0000017981.V317552.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): 1, 2, 3 and 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents benefit from being able to visit the home to help with the decision to move in. The home did not operate a thorough pre-admission assessment process, giving care and attention to ensuring the home was admitting individuals whose entire assessed needs could be fully met. EVIDENCE: The home’s statement of purpose and service user guide contains a wide range of information about the home, including its aims and objectives and the facilities offered. The manager said that these are provided to all prospective residents and that he planned to make some improvements to these documents in the near future. The manager and staff confirmed that all prospective residents are expected to visit Alder House prior to admission, together with their family; this enables an informed choice to be made with regard to the appearance of the home, facilities, food, staff and residents. Three resident care files were selected for inspection. The home had not obtained a Care Management Assessment prior to one individual’s admission to the home, which was an issue that was highlighted at an inspection of the home in 2005. Information provided by the placing authority was inadequate and out of date. The home could not have known whether they could fully meet the prospective residents identified personal and health care needs. Pre Alder House Cheshire Home DS0000017981.V317552.R01.S.doc Version 5.2 Page 9 admission assessment information on two other files checked was comprehensive. The manager was reminded again of the importance of obtaining a full assessment of need and that this is a requirement of the Regulations. Alder House Cheshire Home DS0000017981.V317552.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, 8 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans that are not reviewed on a regular basis and do not inform staff adequately about how care should be delivered have the potential to place residents at risk and for their needs to be met inappropriately. EVIDENCE: As indicated elsewhere in this report, staff were knowledgeable about the needs of each resident, particularly those residents for whom they were the designated key worker. Residents spoken with also felt that staff were meeting their needs in keeping with their wishes. The care records of three residents were checked. These contained a wealth of information gathered from different sources including the wishes of each resident. The records were not easy to follow and staff unfamiliar with the system would find it difficult to extract the desired information. Although the records included a range of objectives for each person, there was no information as to how staff were expected to deliver the service. Much of the service delivery was therefore reliant on staff memory and familiarity with the resident. Alder House Cheshire Home DS0000017981.V317552.R01.S.doc Version 5.2 Page 11 As indicated in the previous inspection report, the positive and informative information gathered was not properly utilised within clear action plans. The sample of records did not indicate that a risk assessment approach had been adopted as part of the decision-making within the care planning arrangements and that appropriate risks had been assessed as part of an encouragement to support an independent lifestyle. Alder House Cheshire Home DS0000017981.V317552.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): 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being offered opportunities to promote and maintain social inclusion and a purposeful lifestyle in and outside the home. Contacts with family and friends were strongly encouraged and well developed. The home supplied a good quantity and quality of food and provided a wellbalanced and nutritious diet that met individuals’ needs. EVIDENCE: The home continues to employ an activity co-ordinator for 30 hours a week, and together with volunteers and care staff, residents are supported in pursuing activities of their choice individually or in groups. At the time of the site visit staff were in the process of finding a horse riding school and arranging for residents to attend. Photographs were available that showed the variety of places residents had visited. Throughout the inspection visit, Alder House Cheshire Home DS0000017981.V317552.R01.S.doc Version 5.2 Page 13 regular contact between staff and with residents was observed, which was friendly and courteous. Residents spoken to said they enjoyed the opportunities to chat with staff and have fun and were satisfied with the type and level of activity available. From discussion with residents, individual choices were accommodated with regard to day-to-day activities. Residents spoke of attending college and shopping in the local areas. Visiting arrangements were open and relaxed and the home promoted contact with the local community. Residents spoken with at the previous site visit in March 2006 felt some staff did not always respect their right to privacy and dignity, especially during the night, however, residents seen on this visit said that staff always knock on their doors and treat them in a dignified manner. All residents spoken with were positive about the meals provided and confirmed that a choice of food was always available. The main meal was not sampled but from observation appeared appetising and residents confirmed they had thoroughly enjoyed the meal. Staff assisted residents with eating appropriately. Breakfast and the midday meal were relaxed and no attempt was made by staff to hurry residents. Menus were available that showed the choices available. The cook kept a note of the selections made each day by residents but a more permanent record in more detail should be kept. The home had two vehicles for the residents, one to take residents to outpatient/GP appointments and the other for leisure activities. Family members are encouraged to book a vehicle to enable family outings to take place. Driving licenses are checked, named daily insurance cover is taken out under the home’s policy and test drives are given and risks assessed. Alder House Cheshire Home DS0000017981.V317552.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 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Alder House provides a safe and well-maintained environment; furnished and decorated to a very high standard that meets residents’ individual and collective needs in a comfortable and homely way. The poor standard of decoration, fittings and tiling in the kitchen could present a health and safety hazard. EVIDENCE: It was evident from discussion with residents that they felt that staff were very aware of their needs and of how they liked to be supported. They considered staff to be sensitive and kind and most having a good sense of humour. Observation of staff in the company of residents showed they were knowledgeable and patient. Records sampled showed good monitoring of health care needs and that appropriate referrals to healthcare professionals were made. Whilst care plan objectives covered personal and healthcare needs, those examined continued to not reflect emotional needs or the support required to promote or maintain independence and quality of life. Alder House Cheshire Home DS0000017981.V317552.R01.S.doc Version 5.2 Page 15 Assessments with regard to identifying actual or potential health risks in relation to moving and handling, dependency level; nutrition, continence needs and potential pressure ulcer detection were recorded within the files inspected. However, not all the assessments had been regularly reviewed to identify changing needs. All of the files sampled held pro-forma statements consenting to the administration of medication by care staff. The pro-forma did not provide adequate assessment information determining considered decisions taken or alternative strategies to care staff assuming control of medication. The care plans identified medication prescribed, however, information relating to the side effects and adverse reactions of medicines being taken by individuals was not readily available. Since the last inspection the home had adopted a Monitored Dosage System (MDS) system with computer generated Medication Administration Record (MAR) sheets. Evidence was available to show that all senior staff designated as responsible to administer medication had been appropriately trained by the pharmacist. The MAR sheets were checked and the senior staff member on duty was informed that one error had been noted. It was also noted that any packets, ointments and liquids were not dated on the day of opening. Controlled drugs were kept in a suitably locked cupboard and appropriately recorded. The care plans sampled contained evidence of individual arrangements for illness and/or ‘end of life’ choices or preferences with regard to their care. Alder House Cheshire Home DS0000017981.V317552.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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an adequate complaints procedure and residents are safeguarded by staff who are trained in the protection of vulnerable adults from abuse. EVIDENCE: The home has a policy on the protection of vulnerable adults from abuse, and since the last inspection had obtained a DVD and information from the Essex Adult Protection Committee, which was to be shown to staff. Records showed that staff had received training from Leonard Cheshire on issues relating to the protection of vulnerable adults. Four staff spoken to confirmed they had received the training and they had a good awareness of the issues. Residents spoken to said they enjoyed the company of staff and felt safe living at the home. A clear and effective complaints procedure was in place. Leaflets were accessible around the home entitled ‘Have Your Say’. Residents spoken to said they felt able to raise any concerns with the staff including the manager, Mr Mahadeo. Alder House Cheshire Home DS0000017981.V317552.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, 25, 26, 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Alder House provides a safe and well-maintained environment for residents, furnished and decorated to a high standard and meets residents’ individual and collective needs in a comfortable and homely way. EVIDENCE: Alder House is a purpose built home providing single bedrooms with en-suite facilities for all residents. A new extension and an extensive refurbishment programme were completed during 2006. Areas of improvements have included an additional bathroom with an assisted bath with a weight limit of 25 stone, two small lounges with facilities for making hot drinks and snacks including a fridge, microwave and kettle, a well-equipped sluice room and the refurbishment of the en-suite facilities to the existing fifteen bedrooms. The hallways and dining room have been redecorated and refurbished with new carpets and chairs. An activities room with excellent facilities including computers is available. Alder House Cheshire Home DS0000017981.V317552.R01.S.doc Version 5.2 Page 18 A tour of the home included a check of many of the bedrooms, which were clean, well furnished and decorated. All bedrooms seen were homely and comfortable and residents spoken to said they had managed to arrange their rooms the way that they wanted and that met their needs. It was apparent that aids and equipment were provided to enable residents to be as independent as possible. The standard of the decoration and the quality of the storage cupboards in the kitchen was poor. Some wall tiles were chipped and staff stated there was a re-occurring problem with a dishwasher that leaks and necessitates a towel being left on the floor. A risk assessment needs to be carried out to determine the need for insect screens to be provided at the windows and external door, which were all open. The manager said that he had made a request for finance to upgrade the kitchen. Alder House Cheshire Home DS0000017981.V317552.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): 31, 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service had not yet achieved an adequate proportion of carers having attained an NVQ qualification in care at level 2 to ensure a competent staff team to support the residents. A thorough and robust recruitment process contributes to the protection of residents. EVIDENCE: The manager gave us information about staff training in September 2006 and stated that only 35 of the current care staff group had successfully achieved a National Vocational Qualification (NVQ) level 2 in care. However, four care staff were expected to complete the qualification in November 2006 and if successful would mean the target of 50 of staff will have been achieved. Staff rosters were seen for the week that showed that six care staff were on duty in the mornings and four in the afternoon and evening. It was clear who was the designated senior staff on each shift. Information given to us by the manager showed that account had been taken of the Department of Health guidance to calculate the number of staff required. A resident spoke of having Alder House Cheshire Home DS0000017981.V317552.R01.S.doc Version 5.2 Page 20 to wait for up to one hour in the morning for an alarm call to be answered. Staff spoken to do not consider this was possible, but the manager will need to address this to establish whether there are delays in responding to calls, particularly between 7.00 and 9.00am when the majority of residents want to get up. Three staff files selected at random showed us that the home’s staff recruitment practice was thorough and that the manager was following procedures. Evidence was available to show that satisfactory references had been received and Criminal Record Bureau (CRB) disclosures obtained. CRB’s had also been obtained for the volunteers helping at the home. Records also showed that staff are provided with supervision sessions on a regular basis, which was confirmed by the staff spoken to. Staff said they received a good level of support and do not hesitate to speak to senior staff when they need to inform or consult with. A selection of staff training records were looked at, which showed that a wide range of training is provided by the organisation. All care staff spoken to confirmed they had received training that was relevant to their jobs, which included the mandatory health & safety elements, POVA and the administration of medication. The activities organiser expressed some disappointment that training opportunities were not available for the job. Alder House Cheshire Home DS0000017981.V317552.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, 38, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the home having an effective management structure in place and an open style of management that encourages residents and staff to give their opinions about the home and the quality of services provided. One aspect of health and safety has the potential to present a risk to residents unless procedures are made clear to all concerned. EVIDENCE: The registered manager, Mr Dilep Mahadeo, is a General Enrolled Nurse and has successfully completed and achieved a NVQ level 4 in Management and Care (The Registered Manager Award). Alder House Cheshire Home DS0000017981.V317552.R01.S.doc Version 5.2 Page 22 Staff spoken to consider the home to be run in an open way, where issues are discussed and senior staff are readily available to provide guidance and support. The quality assurance system, including continuous self-monitoring, care and operational review and results of resident and representative surveys continues to be well managed. The results help to inform development and improvements to the service and links with the community. As at October 2006, staff were being provided with copies of an annual survey that is carried out to gauge staff opinions about the services provided. External people carried out a comprehensive audit of the home during October 2006. The audit included a detailed examination of all matters relating to Health & Safety and a report is to be given to the manager. Information given to us by the manager during September 2006 showed that the servicing of equipment and systems at the home were up to date. These records were therefore not looked at during the site visit to the home. As already indicated in this report under the heading “Environment” the kitchen is in need of being upgraded. Some doubts were expressed at a recent staff meeting about the home’s fire evacuation procedures. Although the manager agreed to seek guidance from the local fire authority and reminded staff of the priorities in the event of a fire, the manager must be clear as to the current arrangements and ensure all staff are equally clear. An Alder House newsletter continues to be produced at three monthly intervals for residents, their representatives, stakeholders and the local community. The newsletter is informative and news items or articles of interest are welcomed. There appeared to be clear lines of accountability both within the home and to external management although information about the structure of the organisation was not apparent in the home. Alder House Cheshire Home DS0000017981.V317552.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 3 2 2 3 2 4 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 3 3 3 3 X X 2 X Alder House Cheshire Home DS0000017981.V317552.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 YA2 Regulation 14 Requirement Timescale for action 01/01/07 2. YA6 YA19 14,15 3 YA24 23 The Registered Person must ensure service users are not admitted until a summary of the single Care Management assessment has been received. Service users are admitted only on the basis a full assessment of needs has been carried out to ensure the home is able to meet those needs. (Timescale of 1/6/06 not met) The Registered Person must 01/01/07 ensure individual care plans cover all aspects of personal, emotional and healthcare needs, regularly reviewed and evaluated with the service user to reflect appropriate planning and/or changing needs and outcomes achieved. (Timescales of 1/9/05 and 1/6/06 not met) The registered person must 01/04/07 ensure the kitchen is upgraded by redecoration, replacing chipped wall tiles and damaged storage cupboards. A risk assessment is required to determine the need for screens DS0000017981.V317552.R01.S.doc Version 5.2 Alder House Cheshire Home Page 25 6 YA42 23 at the kitchen windows and doors. The registered person must consult with the fire authority and ensure that adequate precautions against the risk of fire and evacuation procedures are made clear to all staff. 01/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA35 Good Practice Recommendations The Registered Manager should ensure that training and development are linked to the homes’ service aims and to individual plans particularly with regard to emotional needs. The Registered Person should ensure the minimum of 50 of care staff in the home achieve NVQ level 2 in care. 2. YA32 Alder House Cheshire Home DS0000017981.V317552.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Alder House Cheshire Home DS0000017981.V317552.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. 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