Inspection on 29/03/07 for Allendale

This inspection was carried out on 29th March 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Allendale 18/11/05

Allendale 09/06/05

Allendale 02/02/05

Allendale 12/05/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 Allendale Road 1 Allendale Road Mutley Plymouth Devon PL4 6JA Lead Inspector Megan Walker Unannounced Inspection 29 March 2007 11:00 th Allendale Road DS0000003421.V302626.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 Allendale Road DS0000003421.V302626.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. Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Allendale Road Address 1 Allendale Road Mutley Plymouth Devon PL4 6JA 01752 670247 01752 670247 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) Mr Simeon James Antony George Ramsden The Very Rev Archpriest Benedict Ramsden, Mrs Lilah Ramsden Vacant Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Three service users in the category of Mental Disorder (MD). Age 18 - 65. Date of last inspection 18th November 2005 Brief Description of the Service: 1, Allendale Road is a care home providing personal care (if required) and accommodation for up to three people, aged between 18 and 65 years, with various mental disorders. ‘The Community of St Antony and St Elias’ own it. This is a private sector organisation owning several other care homes in Devon. The home was opened in 1993 and is an end of terrace property, located in a cul de sac in the residential area of Mutley in Plymouth. All the homes bedrooms are single. None of these have wash hand basins or en suite facilities. There is also a lounge room and kitchen/diner for communal use. On the first floor are a staff office and a separate staff bedroom. The home has small back and front yards and all areas are accessible to the people who use this service. The current scale of charges is £1,604.00 to £1,666 per week. No additional charges are recorded. The Registered Provider provided this information to CSCI in March 2007. Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork visit of this inspection took place on 29th march 2007 over a period of about five hours. It included a tour of the premises, observation of staff and residents in the home, talking to residents and to staff, case-tracking residents, inspection of care plans, staff files, medication, and other records and documentation. The manager was not present at the time of this visit, however a Level II Residential Support Worker was able to provide relevant information such as the day-to-day routines as well as the management of the home. In addition other information used to inform this inspection: • The Pre-inspection Questionnaire completed by the home’s manager. • The previous two inspection reports • All other information relating to Allendale Road received by CSCI since the last inspection. Of approximately 15 Comments’ Cards and Surveys sent out, CSCI received back – • 2 Care Workers Surveys Four requirements and two “Good Practice” recommendations were made as a consequence of this inspection. What the service does well: What has improved since the last inspection? Since the last inspection the organisation’s apparent practice of moving staff across its services seems to not to be so. There are a lot of joint activities with staff and residents from its other services, however a core team is in place at Allendale Road. Allendale Road DS0000003421.V302626.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. Allendale Road DS0000003421.V302626.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 Allendale Road DS0000003421.V302626.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, 2,5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents can feel confident that their needs will be assessed before moving into the home and that they and/ or their advocate can have the information they need to make an informed choice about the home. EVIDENCE: Since the last inspection the same people live at Allendale Road. Each person has a written contract. A Statement of Purpose and Service User Guide are available to them, and to prospective residents. The organisation has an admissions procedure whereby all prospective residents are assessed prior to admission. Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 9 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, 9, 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are involved in their individual plan of care and are supported and encouraged to make decisions as part of an independent lifestyle. EVIDENCE: Observation of residents and staff interactions throughout this visit found that each person was consulted about their daily lives. Each person was supported and encouraged to manage their own daily routines and personal decisionmaking within the risk-strategies and restrictions agreed with them. Each person using this service had an individual Care File with a full assessment of their care needs, and a plan of care. Inspection of these files found that they had been reviewed and updated regularly and/or when required. Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 10 Inspection of Daily Logs found that there was a lot of information about each resident written each day. Some staff had a tendency to write about everything each resident had done from the moment they awoke until retiring to bed. It was unclear if this was because staff had not been given clear instructions about recording information, or if this information is required for other reasons. It was also unclear if residents see these Daily Logs to see and agree what is written about them. There was no evidence of any resident’s signature on any of the Daily Logs. There was no other supporting evidence to show that residents had been made aware that they were entitled to have access to any information about them, and had declined this. Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 11 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, 14, 15, 16, 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents have a variety of opportunities to participate in the local community as well as join in suitable leisure activities. EVIDENCE: On the day of this visit the organisation had a session arranged at a local project where it is able to take people approximately every two weeks. This project offers opportunities to join in cutting willow, making clay pots and other woodcrafts. One resident had chosen to go for the day along with people from another of the organisation’ s services’ in Plymouth. All the residents had particular venues in the local community where they liked to spend time. Another resident was planning to go to a local coffee shop after lunch. It was evident from talking to staff, and feedback received from local retailers and suppliers, that good relationships have been established between Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 12 residents and staff to ensure respect and responsibilities are retained as part of people’s daily lifestyles within a public setting. The residents are encouraged to maintain contact with families and friends, and arrangements can be made to facilitate visits for families who do not live locally. On the day of this visit the residents who were at home lunchtime were consulted about what food they would like to eat. Inspection of the Meal Planning/Meal Preparation sheet completed by the staff each shift showed who was involved in planning each meal, who was involved in preparing each meal, the food eaten, and who ate when. It was evident from these that residents can choose to be involved in any/all aspects of each meal from planning to preparation, and that they do not all have to eat the same food or eat with everyone at the same time. The meals recorded were varied with lots of vegetables and salads. They also included an opportunity for “Take Away” meals to be a weekly option on the menu. There was evidence that meals were dependent on staff cooking capabilities and confidence in preparing meals for a group of people. There was no evidence that any staff had completed a “Safer Food, Better Business” training session to comply with the Food Standards Agency regulations and recommendations. The Registered Provider has subsequently informed CSCI in writing that as part of the quality assurance system of the organisation training of all staff on this subject is planned to start from the end of August 2007. Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents can feel confident that a supportive and reliable staff team will ensure that their personal, physical and emotional health care needs are met. EVIDENCE: Observation of the residents and staff found that the residents were prompted by the staff with their personal care in a manner that was unobtrusive and respected individual dignity. External professional advice and guidance was recorded in individual care plans when sought from local health care professionals or social services. One resident spoke about the imbalance of male to female ratio of residents. This was later discussed with a staff member who confirmed that the staff shifts were mixed to ensure that residents had a choice of either a female or male carer. This was both during the day and overnight. In the opinion of the staff spoken to during this visit, the current residents all compliment each other and generally get on well together. It was acknowledged that Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 14 accommodating three residents could always pose difficulties regardless of gender or age. The medication was seen kept in a lockable metal cupboard however the cupboard was not fixed in any way. It is kept in a lockable room. A member of staff commented in a staff survey returned to CSCI that a separate room for dispensing medication would be an improvement on the current location. There was no explanation given about why this would be so. One resident came to ask for their medication and was aware that it was the time to take it. No one at the time of this visit was directly responsible for his or her own medication. On arrival for this visit a manager from another of the organisation’s services was checking in medication that had been delivered earlier by a pharmacist. The medication that was not due to start until a few days later was taken by this manager for storage at the home where he worked. A cause for concern was noted during this visit about the number of incidents relating to medication handling errors that were recorded in the home’s Incident Log. The incidents recorded indicated a possible lack of care and attention by staff when they were administering medication to residents, or an indication that the training being given to staff does not meet guidelines given by the Royal Pharmaceutical Society’s “Administration and Control of Medicines in Care Homes and Children’s Homes”. None of these incidents was reported to CSCI. The Registered Provider has subsequently informed CSCI in writing: “This is an issue that is monitored as part of the reviewing system for accident/incident forms. Concerns can result in retraining for staff, temporary suspension from administering medication or disciplinary action.” House Managers will also be receiving refresher training about reporting of incidents to CSCI. Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents feel that they are listened to and that they are protected from abuse, neglect and self-harm. EVIDENCE: Residents were observed expressing their views and opinions during this visit. A member of the senior management team visits the house regularly, and residents have an opportunity to tell them about any particular ideas or concerns they may have. There are also ad-hoc house meetings if anything arises that residents would like to discuss. Talking to staff members it was evident that issues were more likely to be dealt with as they arose and if necessary other agencies or senior staff in the organisation would be consulted. The organisation arranges in-house training for its care staff so that they would know how to recognise abuse, neglect and self-harm, and deal with it appropriately. Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents live in a safe and homely environment. EVIDENCE: Allendale Road has recently become the property of the organisation, having previously been rented from a private landlord. The Pre-Inspection Questionnaire therefore indicates that there are some maintenance areas that the organisation has “flagged” as part of its ongoing maintenance programme. The house has three storeys although it operates as though it has only two storeys. Access to the top floor is blocked by a door at the bottom of the staircase leading up there. The staircase itself is not blocked in at the top so the top landing is open and the stair rail and ceiling are visible from below. There was a discussion following this visit with the Registered Provider about this arrangement and whether it met fire safety regulations as well as other recent changes to housing legislation. The Registered Provider agreed to check this. Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 17 On the day of this visit work was being done to install a separate shower room and toilet in addition to the existing bathroom. This will improve the facilities currently available for use by both the residents and the staff some of whom are on the premises for up to forty-eight hours as part of their shift pattern. The residents’ bedrooms were personalised and individual in style and arrangement. Each room had a suitable lock so that its occupant could lock their door if they wished. Staff could override these locks in the event of an emergency. None of the bedrooms has an en-suite or wash hand basins. The lounge was comfortably furnished and seen being used by the residents. The kitchen doubled as a dining area. It was restrictive in size although comparative with other domestic housing arrangements such as shared houses or family homes. At the rear of the house is a back yard with garden furniture that is easily accessible to the people living in the house. A member of staff explained that there were plans to set up a gardening project to tidy up the yard and uplift it with some potted plants. The front of the property has a small open area that attracts passers-by and neighbours to discard their rubbish within the boundaries of the house. A member of staff commented that staff had to be vigilant about keeping the external areas of the property clean and tidy to discourage fly tipping. Apparently this has been less of a problem since a neighbour has made changes to their property boundary. Residents’ assist with cleaning the inside of the house and a weekly rota of jobs was seen during this visit. Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are cared for by a motivated staff team however some mandatory training is outstanding for some staff. EVIDENCE: Throughout this visit it was evident that residents were comfortable around the staff team on duty. The staff were respectful to residents. Measures were taken to ensure that the confidentiality of each individual was protected. One member of staff is particularly commended for this. A staff member explained that there is usually a staff team of five allocated by the organisation to work at Allendale Road, usually two on duty at one time, with the manager in addition. Occasionally there is a “floating” staff member so the staff team is able to provide 1:1 support for individuals should they wish it. The Pre-Inspection Questionnaire lists six regular full time staff members (one of whom is still in their probationary period). There are also three regular part time staff members. The Pre-Inspection Questionnaire lists nine Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 19 additional staff members employed by the organisation “who have recently covered holidays, sickness and time out.” Work patterns are variable so some staff work two days with two sleeping nights on, and two days off, for example, Mon and Tuesday, or Wednesday and Thursday, or a weekend – Friday and Saturday or Saturday and Sunday or Sunday and Monday. Some staff always work the same three days each week. This pattern also includes nights sleeping in the house as part of the shift. In total this usually works out to be three shifts in two weeks or the equivalent of six days and six sleeping nights. All the staff employed by the organisation have signed as part of their contract of employment, a European Working Directive disclaimer in the event of anyone should work over fortyeight hours, including overtime in any seven day period. One staff member commented that this arrangement worked in the interests of the residents because there would be the same staff on duty over a forty-eight period. It made it easier to plan daily lifestyle activities such as meals, grocery shopping, and other impromptu activities. It was also reassuring for residents if they woke up during the night, as it would be the same staff still on duty. The weekend arrangement however could be problematic if the Friday and Saturday planning didn’t take into account the whole weekend and a change in staff on Sunday. All the staff files inspected showed that relevant employment checks had been completed. These included police checks and two written references. All the staff had recently been issued with new contracts. They are employed to work for The Community of St Antony and St Elias rather than a specific house to meet the organisation’s’ policy of staff members being able to work in different houses. The policy thereby allows each staff member to become familiar with the needs of all the people who use the services provided by the organisation. It gives a degree of flexibility for “floating” staff. Also, should a clash of personality, for example, arise and it was deemed unsuitable for an individual to continue working in a certain house. Staff files are kept in a lockable filing cabinet. They were not available for inspection because the manager was on annual leave at the time of this visit and she is the only key-holder. Alternative arrangements had to be made by the organisation to provide them. This prompted a discussion with the Registered Provider about the organisation’s current arrangements for access to personnel information, and how this could be modified to improve for future inspections. Inspection of the staff files at a later time, found that some files had certificates for training that were several years out of date. These included mandatory training that should be renewed annually. The Registered Provider was advised about this at the time. Written staff feedback received by CSCI was that staff do not receive formal supervision, and they are observed generally during their work or if they doing Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 20 a National Vocational Qualification (NVQ). The Registered Provider has subsequently informed CSCI in writing that supervision records are held on the personnel files that were not available for inspection at the time of this visit as noted above. Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents benefit from the ethos of the organisation and its’ management of the home that promotes their health, safety and welfare. EVIDENCE: Since the last inspection there has been a change of manager. At the time of this visit the current manager had applied to become a Registered Manager with CSCI and was still awaiting a decision. Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 22 House meetings involve residents in the running and development of the home. The staff Handover Minutes were comprehensive and informative for staff coming on duty. All the records about individual residents were kept in a confidential way. A member of the organisation’s Senior Management Team visits the house regularly, and a report of each visit is sent to CSCI. The house has three storeys. There was a discussion following this visit with the Registered Provider about the fire safety risk assessment of the current arrangement of blocking off the top floor, and whether it met current fire safety regulations. The last Fire Safety Officer visited is listed in the PreInspection Questionnaire as 27th April 2006. This was therefore prior to the change in Fire Safety Regulations in October 2006. The organisation’s policy for recording accidents was found to be complex. At Allendale Road there was an incident book for recording any misadventure so included, for example, medication errors, as well as accidents to residents or staff were recorded. A staff member explained that a carbon copy would be sent to the Senior Management Team who then informed the house staff of any follow up. It was unclear who would take responsibility to inform CSCI of any relevant events in line with the Care Standards Act 2000, Regulation 37 notifications. In light of this, for example, the Pre-Inspection Questionnaire lists two admissions to an Accident & Emergency Department within the past twelve months. CSCI has not received any formal notification of either of these admissions. Likewise, as above, there has been no notification of any medication errors. This concern was discussed with the Registered Provider after this visit. He suggested that some staff might record everything. A review of what to document for all records including Daily Logs as well as incidents was recommended to the Registered Provider. Staff files inspected did not show evidence of all staff doing annual training for mandatory subjects such as infection control, food hygiene, moving and handling, and health and safety in the workplace. Allendale Road DS0000003421.V302626.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 3 3 X 4 X 5 3 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 4 26 4 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X N/A X 3 X 2 2 X Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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(2) Requirement “13 Further requirements as to health and welfare (2) The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home.” The Registered Provider must ensure that medicines received into the care home are kept in accordance with the guidance of Royal Pharmaceutical Society’s “Administration and Control of Medicines in Care Homes and Children’s Homes”. “23 Fitness of premises (4) Subject to paragraph (4A) the registered person shall after consultation with the fire and rescue authority – (a) take adequate precautions against the risk of fire, including the provision of suitable fire DS0000003421.V302626.R01.S.doc Timescale for action 30/04/07 2 YA24 YA42 23 (4) 30/04/07 Allendale Road Version 5.2 Page 25 equipment; (b) provide adequate means of escape; (c) make adequate arrangements – (iii) for the evacuation, in the event of a fire, of all persons in the care home and safe placement of service users;” (iv) for reviewing fire precautions, and testing fire equipment, at suitable intervals” The Registered Provider must ensure that the arrangement of blocking off the top floor of the house meets current Fire Safety Regulations. • The Registered Provider must ensure that when staff check fire safety equipment they have access to check the smoke detector on the top floor. Action must be taken to minimise any other risks identified during the assessment of the house for fire hazards. 37 Notification of death, illness 30/04/07 and other events The Registered Provider must inform CSCI of any incident that affects the health, safety and welfare of the residents. “18 Staffing 31/07/07 (1) The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of the service users – (c) ensure that the persons employed by the registered person to work at the care DS0000003421.V302626.R01.S.doc Version 5.2 Page 26 • 3 YA42 37 4 YA42 18 (1ci) Allendale Road home receive – (i) training appropriate to the work they are to perform…” The Registered Provider must ensure that all staff employed to work in the care home receive annual mandatory training including infection control, food hygiene, moving and handling, and health and safety in the workplace. 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 2 Refer to Standard YA17 Good Practice Recommendations As the current residents are an older group of people, staff may benefit from training on nutrition for people as they grow older. The Registered Provider should ensure that all staff are confident about recording information about residents - i.e. anything written about an individual would not be detrimental or invasive of personal dignity if the individual person were to read it about her/himself. YA41 Allendale Road DS0000003421.V302626.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Allendale Road DS0000003421.V302626.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. 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. 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