Inspection on 25/06/08 for Alpha Community Care

This inspection was carried out on 25th June 2008.

CSCI found this care home to be providing an Adequate service.

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

Alpha Community Care 25/09/06

Alpha Community Care 27/03/06

Similar services:

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Hillview Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Alpha Community Care Green Tiles Home 5 Green Lane Stokenchurch Buckinghamshire HP14 3TU Lead Inspector Barbara Mulligan Unannounced Inspection 25th June 2008 09:30 Alpha Community Care DS0000065938.V365184.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 Alpha Community Care DS0000065938.V365184.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. Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alpha Community Care Address Green Tiles Home 5 Green Lane Stokenchurch Buckinghamshire HP14 3TU 01494 482229 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) barbara@alphacomcare.com Alpha Medical Care Limited Manager post vacant Care Home 4 Category(ies) of Learning disability (0) registration, with number of places Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25th September 2006 Brief Description of the Service: Green Tiles is a small four bedded home intended to provide long-term accommodation for up to four adults with learning disabilities. The home is run by Alpha Medical Care Limited and is their first venture into provision of residential care. The home is located in a quiet residential area on the outskirts of Stokenchurch, a small village approximately 10 miles from the large town of High Wycombe and 20 miles from the city of Oxford. The home consists of a converted bungalow with four bedrooms; one is an ensuite, large lounge, kitchen, dining room and staff office. At the time of this inspection one service user was living at the home. The home charges in the region of £1500 - £2000 per week for placement, with final figures being dependent on the assessed care needs of individual service users. Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection was conducted over the course of a day and covered the entire key National Minimum Standards for younger adults. Prior to the visit, a detailed self-assessment questionnaire was sent to the manager for completion. Information received by the Commission since the last inspection was also taken into account. No survey forms have been received after the site visit was completed. The service users were not able to talk directly with the inspector because of the impact of their disability. The inspection officer was Barbara Mulligan. There is an acting manager in place; Barbara Ditima. However she was unavailable during the inspection and relief, bank, support worker Dave Moodhoo assisted with the inspection. The inspection consisted of discussion with the two staff on duty, opportunities to meet with some service users, examination of some of the home’s required records, observation of practice and a tour of the premises. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. Twenty-six of the National Minimum Standards for Younger Adults were assessed during this visit. Seventeen of these are fully met and nine almost met. As a result of the inspection the home has received ten requirements. The evidence seen and comments received indicate that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. The two staff on duty and service users are thanked for their co-operation and hospitality during this unannounced visit. What the service does well: People who want to live at Greentiles Care Home have their needs assessed before they move in, so staff can meet their needs. The people who live in Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 6 the home enjoy a range of activities. Daily routines in the home are flexible and people can choose when they take part in activities. The home is a comfortable place to live. The home makes sure that the records for medicines are properly completed. What has improved since the last inspection? The home has had a lockable cabinet installed for the safe keeping of medicines. On going improvements Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 7 to the home have been made and provide more suitable furniture in one bedroom. What they could do better: This inspection at the home has shown 10 things need to be done to make it okay. Care plans must be in place for staff and they must be up to date so staff can meet the needs of the people living in the home. Service users are able to make decisions about their lives and staff can show choices have been made. The home must show that all staff who give medicines have had training in the safe handling of medicines. Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 8 The home must send information about any complaints to the inspector. The home must send to the inspector proof that staff have had training in adult protection matters. The home must send to the inspector proof that staff have had an induction and all necessary training has been completed. The home must send to the inspector how people who live in the home, their family and friends are supported to make their views known. The homes fire risk assessment must be up to date. Fire Testing of portable electrical items must be completed every year. Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 9 Staff working in the home must complete Basic Food Hygiene training. . 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. Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 10 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 Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. People who use the service have their needs thoroughly assessed prior to admission ensuring that staff are prepared for admission, and given opportunity to visit the home beforehand to ensure it meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were unable to locate the Statement of Purpose and Service Users Guide at the time of the visit. The inspector requests that a copy is sent to the Commission for Social Care Inspection. At the time of the visit three people were using this service and the inspector observed their assessment documentation. Individual records show that a thorough and detailed assessment of need is completed before admission. This involves visits to potential service users at home, meetings with family and detailed consultation with the placing authority. Potential service users are invited to the home for an initial visit and there is a one-month trial period for parties on all sides to reassure themselves about the appropriateness of placements made. Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 12 A one-month review is organised to discuss the placement and if this has been successful the home are able to confirm the placement on a long-term basis. Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 13 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 and 9 Quality in this outcome area is adequate. The care planning system does not presently provide staff with information they need to satisfactorily meet all service users needs. People who use the service are enabled to make decisions and be as independent as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care of the three people living in the home was case tracked and their care plans were examined. One file examined contains information about the individual being at school and his weekly regime before and after school. However. This person left school almost a year ago. Other areas of this care plan were out-dated and no longer relevant. Another care plan looked at contained no information and the main areas of the care plan were blank. The inspector was told that care plans were being updated and were available on the computer. Some examples of one persons care plan was printed off and examined. This was detailed and comprehensive. However, this information is Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 14 presently not accessible to staff which prevents staff from working to current information. A requirement is made for improvement in this area. The inspector asked how people using the service are involved in the day-today running of the home. There is no evidence available in care plans of how information is presented to service users and how they make decisions. Staff said that there were no residents meetings held and individuals are not involved in menu planning. One staff member said they want to provide laminated pictures of food to help people choose the menus. It is a requirement of the report that service users are enabled to make decisions about their lives and staff can demonstrate how individual choices have been made, and record instances when decisions are made by others and why. There are risk assessments in place for epilepsy, using transport, self-care, unpredictable behaviour and fire safety. These are detailed and show how the risks to the individual are minimised. The risk assessments are dated 2006 and need to be reviewed on a more regular basis. This is strongly recommended. Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 15 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 and 17 Quality in this outcome area is good. Service users have an active lifestyle which reflects their interests, provides them with nourishing meals and have contact with family, friends and the community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One individual left school last year and has since been waiting for the opportunity to attend a day care centre. At the time of the visit the home are still pursuing this. His care plans states “waiting to go to college” but does not detail what he is doing at the present time. Two people who use the service attend activities that are tailored to meet their individual needs. Some of these include trips to the local swimming pool, walks, shopping in the town and visits to a youth club. Daily notes show that on the majority of day’s people living in the home “go for a walk and play with the building bricks.” Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 16 The inspector was informed that each person using the service requires a one to one staff ratio when attending activities outside of the home. The staffing rota shows that there are only two staff on duty. This limits the amount of activities each person can attend and the registered manager must give serious consideration to ensuring there is enough staff support available to enable service users to attend activities of their choice on a regular basis. There are no restrictions about family and friends visiting and people who use the service are supported to maintain family relationships and have regular visits from and to their family. Family members are involved in annual reviews and are invited to social activities. From observations on the day of the inspection visit, staff members were seen to treat the people living in the home with respect and patience. One individual was becoming anxious and distressed and staff responded to him in a respectful and appropriate manner, were patient, gentle and respectful. Mealtime was not observed during this inspection because of anxiety levels of the people using the service. The inspector was informed that staff tend to choose the meals, as they know the likes and dislikes of the three people using the service. The home will offer drinks and snacks throughout the day in accordance with needs of each individual. Nutritional screening is evident in all care plans. Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 17 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 and 20. Quality in this outcome area is adequate. In general residents personal, healthcare and medication needs are met. However, there is a need to ensure that care plans are available to staff which contain current information on healthcare and the home provides evidence that care staff have completed medication training, ensuring their personal and healthcare needs are appropriately met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector was told that the three people who use the service are supported to choose when they like to go to bed, have a bath, have their meals and take part in other activities. However this was not well documented in all care plans examined by the inspector. There is a person centred pen portrait in one file looked at and this shows that daily routines are flexible and this was observed on the day of the visit. One person wanted a drink on several occasions and this was provided on request. There is some evidence of health care screening in one care plan. The individual has epilepsy and there is a detailed support plan in place regarding the management of the individual’s epilepsy. There are also support plans in Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 18 place for working with autistic spectrum disorder, oral hygiene, personal care and maintaining a healthy weight. The two other care plans do not contain much information and the inspector was informed that these are being updated and are available on the computer. One was printed off for the inspector to look at. These are detailed and cover areas such as the support required to help the individual while at home, outside the home, entering a shop and fire safety. The inspector was informed that the home uses an NHS dental service that visits the home regularly and an optical service is accessed via the local medical centre. Specialist services such as physiotherapy, occupational therapy and psychology are accessed via the Community Learning Disabilities Team. Health care information is not presently available and accessible to staff in all care plans, which prevents them from working to current information. A requirement has been made under standard 7 for care plans to be up to date and accessible to staff at all times. None of the people currently using the service are able to self-administer their medicines and named staff are responsible for administering medication. Following the previous inspection a requirement was issued for a suitable separate lockable cabinet is provided for medication storage. It is pleasing to see that this has been complied with. Medication is being well managed by staff and there are detailed guidelines available for staff regarding the safe administration of medicines, homely remedies and guidelines for giving PRN medicines. The inspector examined medication records and these were found to be fully completed with no omissions noted. The inspector asked to look at training records regarding the safe administration of medicines. Staff on duty were unable to locate these. Staff told the inspector that medication training had recently been competed by staff. The inspector requests confirmation that all staff who administer medicines have completed the necessary training and will be a requirement of the report. Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 19 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 adequate. Procedures for managing complaints and adult protection are in place but are not consistently followed to ensure people have accurate information to hand. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has a complaints procedure in place and this includes the timescales for responding to a complaint. The complaints procedure is not available in any other format that may be more suitable for people who use the service and this is strongly recommended. The inspector asked to look at the complaints log but staff were unable to find this. The AQAA received from the home does not include any details regarding complaints. The complaints log must be accessible to staff, to record any complaints received by the home. The registered person is required to provide information of any complaints received by the home to The Commission and must ensure all staff are aware of the complaints procedure and how to record any complaints. The Commission for Social Care Inspection (CSCI) has received one complaint regarding this service since the last inspection. There are adult protection procedures in place and the home has the local authority safeguarding policy/procedure in the home. This is accessible to all staff. A requirement was issued at the previous inspection for staff to be provided with formal training covering adult protection matters. The inspector requested Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 20 to look at the training records but staff were unable to locate them, which means the inspector was unable to assess if this requirement has been complied with. Staff told the inspector they had recently completed Protection of Vulnerable Adults training. The AQAA received from the home does not record any staff training details. It is requested that confirmation of training in adult protection matters is provided to the Commission. There has been one adult protection referral made since the last inspection, according to information supplied before the inspection. Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 21 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, 27, 28, 29 and 30. Quality in this outcome area is good. A comfortable environment has been created for people who use the service, ensuring that they have appropriate surroundings in which to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is suitably equipped in terms of space and facilities to meet the needs of the planned service user group. It is comfortably furnished throughout and maintained to an adequate standard. During the previous inspection it was identified that some areas of the home looked a little sterile and bland and further effort at making both communal and bedrooms areas more homely would be of benefit. A cardboard box was being used as a temporary bedside cabinet – this needed replacement by a proper piece of bedroom furniture. It is pleasing to see that appropriate bedroom furniture is in place. Improvements have been made to the home to try and make it look as homely as possible. The inspector was informed that Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 22 this is an on-going process and slow steps are being made with service users accepting changes to the environment. There are adequate toilet and bath facilities available for people who use the service. The home’s laundry is managed within the home, in a designated laundry room. Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is adequate. The staffing numbers and skill mix is adequate, although these should be monitored carefully to ensure the home can meet all the needs of the people who use the service. Recruitment procedures are adequate although further attention must be paid to ensuring that all recruitment checks are maintained in each persons file to ensure only suitable people are appointed to work in the home. Confirmation needs to be provided to the Commission of the induction and training arrangements, to ensure staff are able to meet service user needs consistently. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels on duty were satisfactory with, currently, two staff on duty in the morning, two staff in the afternoon and 1 staff on a waking night. The home presently has a small group of eight staff providing support and care to service users. Two staff have achieved National Vocational Qualification level 2 or above. As discussed under “Lifestyle” each person using the service requires a one to one staff ratio when attending activities outside of the home. The staffing rota shows that there are only two staff on duty. This limits the amount of activities Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 24 each person can attend and the registered manager must give serious consideration to ensuring there is enough staff support available to enable service users to attend activities of their choice on a regular basis. The main communication method used by the people using the service is Makaton. Staff were observed to use this during the course of the inspection. Three staff files were viewed at this inspection, including those new to the service. The three files examined include the care workers personal details, including next of kin details. All of the staff files seen contain an application form, a copy of terms and conditions relating to the post and evidence of POVA and CRB checks. One file looked at only had one reference. This needs to be addressed. Following the previous inspection a requirement was issued for formal induction training to be completed for all staff in the home and arrangements put in place for completion of all outstanding initial mandatory training courses for staff. Staff on duty were unable to locate training records, they were not present in staff files and the AQAA received from the home does not detail training undertaken by the staff. The inspector was therefore, unable to assess if this requirement has been complied with and the registered person is required to provide confirmation of staff training and induction is sent to the Commission. Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 25 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): Quality in this outcome area is adequate. Confirmation is required of the present management arrangements and Quality Assurance systems within the home. Some improvements to the safe working practices in the home are needed to ensure that service users are protected and promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection there was an acting manager in post. She was not available on the day. The organisation needs to ensure that she is registered with the Commission for Social Care Inspection. Following the previous inspection a requirement was issued that formal monthly monitoring visits by the proprietor are started. The inspector asked to look at these and any Quality Assurance systems undertaken in the home. Staff were unable to locate these and they are not detailed in the AQAA. The Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 26 inspector requires that evidence of Quality Assurance systems, including Regulation 26 reports are sent to the Commission. A range of health and safety checks are in place at the service and carried out on a daily, weekly or monthly basis. The fire alarm is tested on a weekly basis and recorded. There is a fire policy and a fire risk assessment in place dated March 2006. This needs to be updated on an annual basis. The AQAA tells us that Portable Appliance Testing (PAT) was undertaken in June 2006 and needs to be completed. A requirement has been issued for improvement in this area. The AQAA also tells us that no staff have competed Basic Food Hygiene training, although they are expected to prepare meals. This will be a requirement of the report. Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 2 X Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 28 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15(1) Requirement Timescale for action 30/07/08 2 YA7 12(2) 3 YA20 13(2) 4 YA22 22(8) The registered person is required to ensure that care plans are available to staff with up to date information to enable them to fully meet the care needs of service users. The registered person is required 30/07/08 to ensure that service users are enabled to make decisions about their lives and staff can demonstrate how individual choices have been made, and record instances when decisions are made by others and why. The registered person is required 30/07/08 to provide confirmation to the Commission that all staff who are expected to administer medicines have completed training in the safe handling of medicines. The registered person is required 30/07/08 to provide information of any complaints received by the home since the last inspection, to the Commission, and must ensure all staff are aware of the complaints procedure and how to record any complaints. The complaints log must be accessible to staff. DS0000065938.V365184.R01.S.doc Version 5.2 Alpha Community Care Page 29 5 YA23 18 (1)(a) 6 YA35 18(1)(a) 7 YA39 26(5) The registered person is required to ensure that confirmation of training in adult protection matters is provided to the Commission. The registered person is required to provide confirmation of formal induction training completed for all staff in the home and outstanding initial mandatory training courses for staff. The registered person is required to ensure that evidence of any Quality Assurance systems, including Regulation 26 reports are sent to the Commission. The registered person is required to ensure that the homes fire risk assessment is updated annually. The registered person is required to ensure that PAT testing is completed and then undertaken on an annual basis. The registered person is required to ensure that all staff complete Basic Food Hygiene. 30/07/08 30/07/08 30/07/08 8 YA42 23(4)(a) 30/07/08 9 YA42 23(2)(b) 30/09/08 10 YA42 18(c) 1 30/09/08 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 YA9 Good Practice Recommendations It is strongly recommended that risk assessment documentation is reviewed at least annually. Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Alpha Community Care DS0000065938.V365184.R01.S.doc Version 5.2 Page 31 - 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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