CARE HOME ADULTS 18-65
Apple House 186 Seafield Road Bournemouth Dorset BH6 5LJ Lead Inspector
Heidi Banks Announced Inspection 22 February 2006 10:00
nd DS0000063160.V283992.R01.S.doc Version 5.1 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 DS0000063160.V283992.R01.S.doc Version 5.1 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. DS0000063160.V283992.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Apple House Address 186 Seafield Road Bournemouth Dorset BH6 5LJ 01202 429093 01202 773410 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) Apple House Limited Mrs Jane Elizabeth Montrose Care Home 4 Category(ies) of Learning disability (4) registration, with number of places DS0000063160.V283992.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to be admitted must be ambulant and able to manage stairs. 16th December 2005 Date of last inspection Brief Description of the Service: Apple House is a residential care home registered to accommodate a maximum of four adults with a learning disability. Apple House is a semi-detached house located in the Southbourne area of Bournemouth. The property is in keeping with the neighbourhood. It is situated within easy reach of local shops and community facilities. The home has a vehicle which can seat seven people. There is on-road parking at the front of the house. Bus routes to Christchurch, Boscombe and Bournemouth are easily accessed. Accommodation is provided in single bedrooms. Three bedrooms are on the first floor of the property, one of which has its own en-suite facilities. There is one bathroom for shared use by three residents. One bedroom is situated on the ground floor. The home has an attractively decorated and furnished lounge, kitchen and dining room area. There is a patio area and garden to the rear of the property for use by residents. DS0000063160.V283992.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was announced and took place over the course of nine hours on a weekday. The purpose of the inspection was to assess the home’s progress in meeting the two recommendations made at the last inspection and to assess outcomes for residents against some of the National Minimum Standards. The inspector was assisted by the Registered Manager, Jane Montrose, throughout the visit. There are four residents living at Apple House at the present time. One resident had moved in the previous week. The age range of the residents is currently between 32 and 59. For the purpose of this inspection information was obtained from the Registered Manager, two staff on duty and three of the four residents. A sample of records was also inspected including service user files, staff files and some records relating to medication and health and safety. Fifteen standards out of the twenty-two key standards were assessed at this inspection. What the service does well:
Residents’ records demonstrated that prior to admission full assessments are carried out by Social Services which identify the individual’s requirements. This ensures that the home is able to make suitable arrangements to meet the needs of the prospective resident. Discussion with residents and staff indicated that residents are supported to make decisions and choices which give them some control over their everyday lives and aspects of their home environment. Residents are encouraged to identify and follow through activities and educational opportunities that are of interest to them and offer them inclusion in their community. There is evidence that residents are encouraged to maintain contact with family and friends and that significant people are involved in service user reviews if this is the individual’s choice. The home presents as clean, attractively decorated and comfortable providing a pleasant environment for residents that meets their needs. All three full-time staff at the home have completed an NVQ in Care which means that they have a sound knowledge base to provide effective support to residents. The manager is aware of her responsibilities in running the home, shows commitment to improving the quality of care for residents and was seen to be approachable to residents and staff during the inspection. DS0000063160.V283992.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better:
As a result of this inspection, four requirements and six recommendations have been made. An immediate requirement has been made in relation to fire training and fire drills. Although staff are introduced to fire procedures at induction, there is currently no formal fire training in place for staff to ensure that they know how to respond in the event of a fire. There were no records to show that fire drills had taken place at the home which means that staff and residents have not had the opportunity to practice the action they would take in the event of a fire. In addition, a requirement has been made that, where tests are carried out on smoke alarm and heat sensor equipment in the home, records must be kept of which alarm or sensor was tested on each occasion to ensure that they are all tested regularly. Staff files sampled indicated that appropriate checks had not always been carried out by the home prior to staff commencing in post. This means that recruitment procedures are not robust enough to fully protect residents. The home’s quality assurance strategy is in its early stages of development. This will need to be fully implemented to ensure that the views of residents are central to the development of the home. Although individual plans for residents are in place, there was no evidence in the file sampled that the resident had been consulted in the drawing up of the plan or that information within the plan had been shared with him. The plan sampled was in written format but as the resident is unable to read it is therefore not in a format that is accessible to him. DS0000063160.V283992.R01.S.doc Version 5.1 Page 7 Some recommendations have been made around the administration of medication to ensure that procedures within the home fully protect residents. The manager should identify suitable abuse awareness training for staff so that they are aware of how to recognise different forms of abuse and know the local procedures for responding to any abuse they may witness or suspect in relation to the residents they support. The home should ensure that induction training undertaken by their staff meets Skills for Care specifications and that evidence of this is maintained on staff files. Development of the home’s training programme for staff has been recommended to ensure that staff have the necessary specialist knowledge and skills to be able to meet the diverse needs of residents. Risk assessments around various substances used for cleaning in the home should refer to the actual products being used so that risks are minimised and the health and safety of staff and residents is fully protected. All staff should know where the accident record book is kept in the home so that, in the event of an accident occurring, they are able to access it easily to make a timely record of events and any injury sustained. 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. DS0000063160.V283992.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000063160.V283992.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home ensures that the needs of prospective residents are assessed so that suitable arrangements can be made to meet their needs and they avoid offering places to people whom they cannot adequately support. EVIDENCE: The records of a resident recently admitted to the home were examined. These showed evidence of a Community Care Assessment of Needs undertaken by his Care Manager and assessment documentation from various health care professionals. These provided comprehensive information about the individual’s history, needs and aspirations. There was evidence on file of liaison between the resident’s previous placement and the home to promote a smooth transition. Discussion with the resident concerned indicated that he had been involved in the process and that his needs and aspirations had been considered. At the time of the inspection, staff at Apple House were producing an action plan with the resident detailing things he would like to do while living at the home. DS0000063160.V283992.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 7 Further development of individual plans is needed to evidence that residents are involved in the process and that plans are in a format that is accessible to them. Residents are supported to make decisions about their own lives and become involved in aspects of the running of the home. EVIDENCE: The support plan of one resident was examined. This included information about what staff must know in order to support him, his likes and dislikes and what staff must know to keep him safe. The plan included information on getting up, bathing and showering, day care, bedtime, night care, independent living skills, social activities, health, mobility, transport, medication communication, family, mealtimes and handling money. The plan had been signed and dated by the member of staff responsible for its compilation. It was not possible to decipher the staff member’s signature. It was noted that the resident himself had not signed up to the plan and therefore there was no evidence that he had been involved in its compilation or that the information in the plan had been shared with him. The plan reviewed was in written format and did not include any pictures, photographs or symbols that may make it
DS0000063160.V283992.R01.S.doc Version 5.1 Page 11 more accessible to the resident. Some parts of the plan had been left blank. Discussion with staff indicated that this meant that there were no issues. It was suggested that this should be written clearly on the plan. House meetings are held every six or eight weeks. To date, these have been informal and minutes of the meetings have not been kept. The manager is intending to make links with a local advocacy organisation so that the meetings are chaired by an independent person not linked to the home. Discussion with staff and residents indicated that residents are involved in decision-making including meal choices, grocery shopping and the activities they choose to do on a daily basis. One resident has recently purchased a computer and a new bicycle to enable him to pursue his interests. DS0000063160.V283992.R01.S.doc Version 5.1 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 Residents are encouraged to take part in activities which interest them, offer opportunities for inclusion in their community and which enable them to pursue their personal goals. Residents are encouraged to maintain contact with family and friends and build networks of support for themselves outside of the home. EVIDENCE: Discussion with one resident demonstrated that he has been supported to attend college to do a horticultural course and also undertake a computer course in the community. During conversation he reported that he was looking to get a job, possibly as a hospital porter or in a catering environment. The manager reported that he is currently on the waiting list for a programme at the Job Centre which will offer him individual support for a limited period to find and start paid employment. Two residents at the home prefer home-based activities and the manager reported that she is working with them to identify things they might enjoy.
DS0000063160.V283992.R01.S.doc Version 5.1 Page 13 This has included home-based sessions in art and creative therapy with a qualified art therapist. The home has employed a part-time Activities Co-ordinator who facilitates a weekly one to one session with service users. The manager reported that residents choose what they do with this time but it is an opportunity for them to work towards goals or go somewhere new in the community. One resident’s individual plan indicated that his goal is to integrate into the local community and work towards more independent living. A part-time Support Worker has been employed with the specific role of facilitating this process and they are looking together to identify courses and activities in the community that will help him work towards his aims. The manager reported that residents are encouraged to maintain contact with their families. Some residents have regular visits from members of their family and family members are invited to review meetings about their relative as appropriate. One resident regularly cycles to the neighbourhood in which he used to live to meet with people he knows and has a friend whom he maintains contact with. Residents are able to use the home’s telephone to maintain contact with their friends and family and the cost of this is included in their residential fees. DS0000063160.V283992.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Further development of the home’s practices and procedures around administering medication will ensure that service users are more fully protected. EVIDENCE: The home has a policy around the handling and safe storage of medication. The action that staff should take in the event of making an error when administering medication is not included in the policy. Medication is stored in a locked cupboard in the home’s kitchen. The member of staff on duty is responsible for administering medication to residents. Medication is supplied by a local pharmacy in the form of a monitored dosage system. All staff have completed a short training session on the use of the system and the manager is purchasing a one day ‘Basic Pharmacology’ training course from the pharmacy for all staff so that they have a greater awareness of medicines, their side effects and interactions. A sample of medication administration record (MAR) charts were checked. It was noted that for a newly admitted resident, details of his prescribed medication had been added to the MAR chart by a member of staff.
DS0000063160.V283992.R01.S.doc Version 5.1 Page 15 Residents’ allergies had not been included on the MAR charts. The manager reported that a course of medication for one resident had recently been discontinued by his Community Psychiatric Nurse. The manager stated that all staff had been informed about this and the resident’s MAR chart indicated that the medication had not been administered to him since this date. However, the medication had not been crossed through on the MAR chart with the date that it had been discontinued. The medication concerned had not yet been returned to the pharmacy. The procedure for taking verbal instructions from medical practitioners about changes to residents’ medication was discussed. The manager reported that the team have been instructed that two members of staff must hear the information and record it. The manager stated that she would usually be contacted with this information by staff and she would then take responsibility for following the action through. There was evidence from the MAR charts that certain over-the-counter medicines are used for residents as required. There is no homely remedies list in place at the home to indicate which over-the-counter remedies are used for what purpose and their possible side effects and interactions for the information of staff. DS0000063160.V283992.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Training for staff on abuse awareness should be implemented to ensure that staff are able to recognise abuse and know how to respond effectively. EVIDENCE: The home has a policy on abuse which is introduced to staff at induction. Information about the action to be taken in the event that abuse is suspected is also contained within the Staff Handbook and Training Manual. The manager has produced a flowchart for the information of staff and service users about the process to be followed in the event of an adult protection issue being raised. The manager demonstrated her awareness of the action she would need to take in the event of adult abuse being suspected including the notification of appropriate bodies. The manager confirmed that procedures around recording residents’ money have recently been reviewed to ensure that they are protected from financial abuse. The manager was unable to locate information about the home’s whistle blowing policy in the Staff Handbook at the time of inspection but confirmed that she would ensure that this is included. Formal abuse awareness training has not been identified for staff. DS0000063160.V283992.R01.S.doc Version 5.1 Page 17 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Residents live in a comfortable home which meets their needs and allows them to exercise their personal choice with regards to the decoration and furnishing of their own rooms. Systems and procedures are in place to ensure that good levels of hygiene are maintained and that residents benefit from living in a clean environment. EVIDENCE: The home is in-keeping with properties in the neighbourhood and residents are supported to access their local community by using the home’s vehicle or by public transport. Furnishings and fittings throughout the home are domestic and unobtrusive. Residents’ bedrooms have been decorated to meet their own personal tastes and some have brought their own furniture with them from their previous residential accommodation. The home presents as clean and comfortable. The home uses a handyman service for property maintenance and repair purposes. During the inspection, a plumber visited the home regarding the repair of fixtures and fittings in the shower. DS0000063160.V283992.R01.S.doc Version 5.1 Page 18 The manager talked through the redecoration that has taken place since the home was registered in February 2005. Residents have been encouraged to choose their own décor for their rooms when they move in. The manager stated that she keeps a record of maintenance and renewal that is undertaken within the home but this is not kept on the premises. The home has an infection control policy and the manager is the infection control lead for the home as she has a particular interest and commitment to this aspect of care. Aprons and gloves are accessible to staff when they support residents with personal care tasks. The home also has a hand hygiene policy and hand washing procedure which promotes the importance of good hygiene in the home. These procedures are introduced to staff at induction. The manager reported that one member of staff will be undertaking infection control training at a local hospital in the near future and will be responsible for sharing up-to-date information with the rest of the team at staff meetings. There is a cleaning schedule at the home which lists tasks that should be done on a daily, monthly and quarterly basis to maintain a clean and pleasant environment for residents. Residents are supported to be involved with these tasks. DS0000063160.V283992.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Residents benefit from having suitably qualified and knowledgeable staff supporting them in their everyday lives. Improvements are needed in the collection of essential documentation to ensure that recruitment procedures are comprehensive and fully protect service users. The home’s training programme needs further development to ensure that all staff access LDAF accredited training and other mandatory and specialist training courses that reflect the needs of the residents they support. This will enable them to have the specific knowledge and skills to meet the requirements of individual residents. EVIDENCE: There are currently three full-time staff and three part-time staff working at Apple House. All full-time staff have an NVQ in Care or Promoting Independence at Level 2 or Level 3. The manager reported that she is looking to set up Learning Disability Award Framework accredited training and further NVQ training for all staff at Apple House. The manager reported that staff recruited through employment agencies have already undertaken an induction programme prior to coming to work at the home. Evidence of the content of this induction training and how it
DS0000063160.V283992.R01.S.doc Version 5.1 Page 20 meets the Skills for Care induction standards needs to be maintained on file. The manager reported that all staff have undertaken emergency first aid training as part of their induction and some staff have undertaken food hygiene training. It was not clear whether all staff had undertaken training in moving and handling. The home is introducing an in-house induction process which covers fire procedures, support plans, risk assessments, money handling procedures, medication, mobility aids, transport, reporting procedures, adult protection procedures, complaints and lone working. The manager is aware of the need for staff to receive specialist training which reflects the needs of the individuals they support. She reported that she has asked staff to identify an area of training that interests them, and which they can demonstrate would benefit service users, as part of their personal and professional development. This is to be formalised as part of the home’s appraisal and supervision process. The majority of staff working at Apple House are recruited through two employment agencies. Staff from the agencies are appointed on a thirteen week trial basis and once this is completed, and if their performance is deemed satisfactory, they are appointed on a permanent basis. Copies of staff personnel documentation are held at Apple House with original documentation held at the proprietor’s other home in the local area where there is specific office space. A sample of three staff files was examined. In one case a member of staff had been employed at the home since 1st October 2005 but references had not been received by the home until approximately three months later. The manager confirmed that this had been an oversight and as soon as she had realised that references were not on file she had suspended the member of staff concerned until they had been obtained. The same staff file showed a gap in employment history for the period before taking up employment at Apple House which had not been explored with the member of staff. A copy of a Criminal Records Bureau (CRB) check dated July 2005 was on file but this was in the name of a previous employer. In another staff file, there was no evidence of a reference being taken up from the individual’s last employer. All files examined showed evidence of proof of identity. DS0000063160.V283992.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The Registered Manager is aware of her duties and responsibilities and residents benefit from her ability to run the home well. The quality assurance strategy at the home needs to be fully implemented to ensure that residents’ views underpin the development of the service. Shortfalls in staff fire training and fire drills mean that residents are currently not fully protected with regards to fire safety within the home. EVIDENCE: During the inspection process the manager demonstrated her awareness of her responsibilities and showed commitment to meeting the National Minimum Standards. Observation of interactions between residents and the manager showed that they find her approachable and easy to talk to. It is clear that she plays an active role in the residents’ lives and supports them in attending medical appointments, reviews and takes an interest in their everyday activities. Staff on duty indicated that they find the manager easy to talk to and were supportive of her approach and management style.
DS0000063160.V283992.R01.S.doc Version 5.1 Page 22 The manager reported that she has developed a questionnaire to be used as part of the home’s quality assurance process. She reported that this is in an easy-to-understand format and will be sent out to residents, their relatives / friends, health care professionals and care managers who have involvement with residents at the home. Fire safety records were inspected. There are two smoke detectors and one heat sensor at the home. A system of weekly checks of this equipment has been established but it was not clear from the records which detector / sensor had been tested on each occasion. There was no record to evidence that fire drills have been carried out at the home since its registration as a care home in February 2005. There is no formal fire training in place for staff although the manager confirmed that procedures are discussed with staff on their first day of employment. Instructions of what to do in the event of a fire are on display in the hallway of the home, next to the telephone. An accident book is in place at the home but a member of staff on duty at the time of inspection was not able to say where it was kept. Procedures to be followed for reporting an incident or accident are available to staff in the Staff Handbook. Household substances which are potentially hazardous to health, for example, cleaning fluids, are stored securely in the home. Information about Control of Substances Hazardous to Health (COSHH) regulations is included in the Staff Handbook. Risk assessments have been carried out on some household substances but these did not always correspond with the actual products being used. DS0000063160.V283992.R01.S.doc Version 5.1 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 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 X 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 X 2 X X 1 X DS0000063160.V283992.R01.S.doc Version 5.1 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. Standard Regulation Requirement The registered person must make arrangements for persons working at the care home to receive suitable training in fire prevention. The registered person must ensure, by means of fire drills and practices at suitable intervals, that the persons working at the care home and, so far as practicable, service users, are aware of the procedure to be followed in case of fire, including the procedure for saving life. The registered person must not employ a person to work at the care home unless full and satisfactory information is available in relation to him in respect of each of the matters specified in Schedule 2 of the Regulations. Where testing is carried out of smoke alarms and heat sensors within the home, records must be kept that clearly state which alarm / sensor has been tested on each occasion. The registered person must ensure that the home’s quality assurance process is fully implemented.
DS0000063160.V283992.R01.S.doc Timescale for action 1. YA42 23 23/02/06 2. YA34 19 30/04/06 3. YA42 23 30/04/06 4. YA39 24 30/06/06 Version 5.1 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The involvement of the service user or his / her representative in drawing up the individual Plan should be indicated on the Plan with evidence that the information has been shared with the service user. The individual Plans should be made available in a language and format that the service user can understand and should be held by the service user unless there are clear, and recorded, reasons not to do so. Guidance from the Royal Pharmaceutical Society should be followed with regards to the receipt, recording, storage, handling, administration and disposal of medicines. When entries on MAR charts are handwritten, a second competent person should sign to confirm that all the details of prescribed medicines are correct. An agreed list of over the counter remedies should be compiled for service users specifying which medication should be used for what purpose and the possible side effects and interactions of the medications. Procedures for taking verbal messages from medical practitioners regarding medication and obtaining written confirmation should be added to the medicines policy. The action to be taken by staff in the event of an error being made in relation to administering medication should be added to the medication policy. Medication that is discontinued should be clearly marked and dated on the medication administration record and returned to the pharmacy. Residents’ allergies should be added to the medication administration records. The Registered Manager should ensure that suitable arrangements are made for staff to receive training in the protection of vulnerable adults. The registered person should ensure that staff receive structured induction training and foundation training which meets the specifications of Skills for Care. Each member of staff should have an individual training and development assessment and profile.
DS0000063160.V283992.R01.S.doc Version 5.1 Page 26 1. YA6 2. YA20 3. YA23 4. YA35 5. YA42 6. YA42 Training and development should be linked to the home’s aims and reflect the needs of service users. The registered person should ensure that where risk assessments have been carried out for various chemical substances used within the home, they correspond to the actual products being used. All staff working at the home should be aware of where the accident book is kept and know how to complete it in the event of an accident occurring. DS0000063160.V283992.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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