Inspection on 08/09/08 for Ashburnham Road, 95

This inspection was carried out on 8th September 2008.

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

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

Other inspections for this house

Ashburnham Road, 95 25/05/07

Ashburnham Road, 95 21/06/06

Ashburnham Road, 95 31/10/05

Ashburnham Road, 95 13/04/05

Ashburnham Road, 95 13/01/05

Ashburnham Road, 95 04/08/04

Ashburnham Road, 95 17/02/04

Ashburnham Road, 95 05/08/03

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 Ashburnham Road, 95 Luton LU1 1JW Lead Inspector Andrea James Unannounced Inspection 8th September 2008 10:00 Ashburnham Road, 95 DS0000014989.V371845.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 Ashburnham Road, 95 DS0000014989.V371845.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. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashburnham Road, 95 Address Luton LU1 1JW 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) 01582 481589 F/P 01582 481589 No email on 3/7/2007 Advance Support Ltd Mrs Bertha Kamuna Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2007 Brief Description of the Service: Advance Housing and Supported Living is a voluntary organisation that provides homes in the community for people with learning disabilities and mental health needs and owns 95 Ashburnham Road residential home. The home is a three-storey building. The home is situated in Luton and provided care for four adults in the category of mental disorder. All the bedrooms are single and service users are encouraged to personalise their bedrooms. People have their own bedrooms. A pay phone, bathroom, and toilet are located on the second floor. The top floor is used for the staff sleeping-in room. The ground floor has a lounge/diner, toilet a kitchen and the manager’s office. The office is accessed via the kitchen next to the utility room. Both the staff and people using the service have access to the garden, which is situated at the back of the home. The home is within walking distance of the park, shops, pub and a bus stop. The Town centre of Luton is three miles from the home. The minimum fee charged per service user was £540/- per week and the maximum was £ 580/- per week. Ashburnham Road, 95 DS0000014989.V371845.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 the service is a 1 star. This means that people who use this experience an adequate quality outcome. This was an unannounced inspection carried out on the 10th of September 2008. The registered manager was present for the duration of the site visit which lasted for six hours. The report consists of information received from people using the service, care staff and the manager, other evidence was also gathered from questionnaires and the AQAA (Annual Quality Assurance Assessment). The report followed a case tracking methodology where a sample of people were selected at random to see what it was like for them living at the home. These peoples care plans were inspected and where possible they, their key workers, and staff were spoken to. What the service does well: The service provides 24 hour care to people needing support in a long-term residential placement. The healthcare needs for people were satisfactorily maintained and the home had good working relationships with external professionals. The staff team received satisfactory levels of training which resulted in effective service delivery to people using the service. The team received adequate support and supervision on a regular basis and were competent in meeting the needs of people in the home. The home ensured people received activities and their lifestyle helped to promote their independence. Good nutritional standards were maintained and the menus seen suggested choices were offered to people on a daily basis. People were supported in a positive way in order for them to maximise and develop their independence and where this was not possible the team were proactive in identifying the needs of people using the service. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home should ensure that. • • • • • • • • Water temperatures are of a satisfactory temperature that will not cause scalds or burns to people using the service. The garden is made welcoming for people to enjoy Specialist training is provided for the staff team to include mental health. Risk assessments are implemented to avoid unnecessary risk to the health or safety of people in the home. The fire authorities are consulted in regards to doors propped open. Food opened and stored in the fridge and cupboards are labelled and correctly sealed in accordance with the food hygiene requirements. Consistent care planning and needs assessments are available in all files. The quality assurance system is developed to ensure the views of people using the service are analysed and published. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 &5. People who use the service experience an adequate quality outcome in this area. We have made this judgment using a range of evidence to include a visit to the service. Satisfactory system were in place to ensure people received enough information about the services the home offered, further development was needed to ensure all people had satisfactory assessments upon admission, as a result some peoples needs could be unmet. EVIDENCE: The home had a Statement of Purpose and a Service User Guide that was reviewed and updated in June 2008. The information enclosed in these documents provided people with sufficient resources to access the services offered by the home. Policies and procedures were in place for assessing people’s needs upon admission and before. This document was seen in some peoples files but was not consistent for all the users of the service. The recent admission to the home had satisfactory documentation that would suggest the current procedure provided the opportunity for people to receive a comprehensive assessment. Some documents inspected failed to show how the team were able to identify and implement a care package as the need assessment was not available. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 10 The home had satisfactory procedure is in place for potential people to visit and test drive the home. One person who recently moved into the home said he was given the opportunity to have respite care before his placement became permanent. This information was also relayed by the staff team and the manager. Peoples files inspected showed that contractual agreements were implemented for all users. These agreements were signed and dated by the people using the service and the providers of the service. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7,8&9. People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Opportunity was given to people to enable them to make decisions, participate in life in the home, and take risks where necessary, however further development was needed to ensure these opportunities are accurately reflected in individual care plans; as a result people could receive inconsistent service delivery. EVIDENCE: The home created opportunities for people to maximise their independence in the way they lived. Recorded evidence suggested people were enabled to make decisions about their lifestyles. People were able to access resources such part time voluntary work, visiting family and friends assisting with food shopping. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 12 One person spoken to said, I go to work on Mondays and other days I have a walk and look around the shops”. Another person spoken to said, “I help to clean the kitchen and my bedroom and I visit my girlfriend three times per week”. The staff team also encouraged and assisted people in areas of health care for example some people were encouraged to self- medicate, people were escorted to the GP. We inspected care plan documentation and found that for the most recent admission satisfactory care plan documentations were in place that were signed and dated by the user, the manager, key worker and a social worker. The plan clearly identified the needs of the person in regards to physical health, optician, death, medication, activities, relationship, budgeting and terminal illness. Various guidelines were implemented to reflect the mental health conditions of this person to include relapse indicators and risk assessments. It was concerning however to know that a comprehensive assessment was not undertaken and as a result it was not possible to identify if the holistic needs of the person was being met. There was evidence to suggest the care plan was to be reviewed two months ago but it had not been achieved. The risk assessments identified for this user did not clearly show the level of risk and some areas needing to be risk assessed had not been implemented. A risk identified on the day was that one person smoked in his bedroom and did not follow the procedures, which was to go to the utility room. The second care plan inspected showed that satisfactory needs assessment was undertaken but care plan intervention was not available and as a result it was not possible to ascertain if the staff team were able to provide a consistent service delivery to this person. The home was proactive in identifying the needs of the people using the service and where they were no longer able to meet the needs of people due to their deteriorating health they had notified the authorities. There was evidence that reassessment of needs was undertaken and an enablement plan implemented. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,16&17. People who we use the services experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. People living at the home received appropriate leisure activities, personal development that enabled them to access community resources and receive good nutritional meals; as a result peoples lifestyles were enjoyable. EVIDENCE: The home ensured opportunities for personal development were provided for people who had the potential to develop both physically and mentally. People spoken to were able to express individual personal development plans and for some this was already a reality. One user said, “I go to work once a week and enjoy meeting people”. Another person expressed his desire to attend college to study computers. The staff said this was a possibility once the person stabilised mentally. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 14 One person said he was able to take the train and bus on a regular basis to visit his girlfriend in another town. This person explained that staff encouraged him to develop to his full potential. Opportunities were also made available for people to attend clubs and various forearms within the community. One person who was experiencing limited mobility was also encouraged to access leisure activities with one-to-one staffing using a wheelchair. The nutritional intake for people living in the home was of a satisfactory standard. The menus seen suggested people were given a choice in what they wanted to eat. During the inspection people were observed accessing the kitchen facilities to prepare individual snack and beverages. People spoken to said they helped to prepare the meal, go shopping and choose what they wanted to eat. One person who was diabetic also had his needs met in regards to nutritional meals. The Food stocks within the home appeared satisfactory and staff spoken to said a balanced meal was prepared on a daily basis and all the residents sat and ate together. Some foods opened in the fridge and cupboards were not labelled and as a result could be deemed unsafe for consumption if it is not possible to know when the product was opened. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. People received satisfactory support with emotional health needs, safe medication procedures, and as a result were supported in healthcare issues. EVIDENCE: The home had made arrangements and implemented guidelines to ensure the personal and health care needs of people are addressed in accordance with the needs assessments identified at the onset of the care package. One person had the support of various district nurses, therapists and counsellors to enable mental stability and improved health. This person explained that he had regular visits from nurses. This information was also recorded in other documents inspected. District nurses visited the home to give injections and dispense controlled drugs. The staff team and the manager were able to explain the effectiveness of external professionals helping to ensure people do not relapse. The home had satisfactory policies and procedures for the safe administration of medication. The procedures for receipt, Administration, and recording of medication were of a satisfactory standard. One person said he was able to Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 16 self- medicate and guidelines seen suggested staff enable this person to do so safely. People receiving controlled drugs were also supported to do so safely by the staff team. The storage recording and Administration of this process was inspected and found to be satisfactory. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience a good quality outcome in this area. We have made a judgment using a range of evidence to include a visit to the service. The policies and procedures in place for listening to people and safeguarding them from abuse was of a satisfactory standard, as a result people were protected. EVIDENCE: The home had comprehensive complaints policies and procedures in place and people spoken to said they knew how to complain if they had any concerns. The complaints procedures were also seen displayed in the Service User Guide in the communal area of the home. We were informed that the home have received no formal complaints since the last inspection. Referrals made in recent months and the processes in place suggested all procedures were followed to protect the people using the service. The Commission was aware of these referral. People spoken to said they received Safeguarding training and knew what to do in protecting people from abuse. Staff training records inspected showed that most of the staff team were trained in Safeguarding of Vulnerable Adults (SOVA). Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28 & 30. People who use the service experience a poor quality outcome in this area. We have made this judgment he was in a range of evidence to include a visit to the service. The environmental standards in the home were satisfactory to promote comfort, privacy and independents to people but the hot water temperatures dispensed from taps were unsatisfactory and could put people in danger of burns or scalds, as a result people were not safeguarded. EVIDENCE: The home was clean and welcoming and free from offensive orders. It was decorated to a satisfactory standard and the furnishings were modern. We were given a tour of the home and people invited us into their bedrooms which were decorated to an individual taste. Some bedrooms appeared to have very little personal items but staff spoken to said some people using the service refuse to have pictures on their walls and anything in their bedrooms apart from what is there. People spoken to said they enjoyed their bedrooms and some took pride in cleaning it on a daily basis. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 19 The hot water dispensed in the house was dangerously hot for people when wishing to use the hot water taps. We identified that in all bedrooms bathrooms and communal areas of the home water dispensed from hot water taps could cause serious scalds and burns. On the day of the inspection an immediate requirement was issued to the home to ensure the temperature of the waters were regulated to protect people. We observed that a maintenance engineer was sent out on the same day to regulate the boiler but staff say this was only a short-term measure as the temperature of the water often changes. The home provides satisfactory bathing, showering facilities and toilet facilities for people in the home. One user had to purchase equipment for assisting him in bathing due to the deterioration of his health resulting in limited mobility. The communal areas of the home provided sufficient space for lounging and dining with separate utility room for laundering and ironing of clothes. Staff and people using the service wishing to spoke were encouraged to use the utility room at the back of the building. One user had refused to follow this procedure and was smoking in his room. The home had not implemented a risk assessment to manage this situation. The staff team and people using the service took responsibility for the daily cleaning off the home and people spoken to said this was done on a rota basis. The staff was observed to support one person to clean his room and launder his clothes. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. People who use the service experience an adequate quality outcome in this area. We have made this judgment using a range of evidence to include a visit to the service. People living in the home were supported by a staff team that were trained, competent, supervised and skilled in providing care, further development was needed to ensure specialist training provided was up to date, as a result people’s needs could be compromised. EVIDENCE: The home followed satisfactory procedures for recruiting. Two staff files inspected suggested satisfactory clearances and references were obtained prior to the commencement of staff being employed. Staff spoken to said they received satisfactory training. Records inspected suggested mandatory training was undertaken by all the staff team.4 of the 6 staff had achieved their NVQ level 3 in care qualification. Training records seen suggested staff received training in safeguarding, first aid, manual handling, violence and aggression, effective communication, Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 21 infection control, medication, risk assessment and diabetes but some specialist training required refreshing for example the training for dementia and mental health was not obtained for any of the staff team since 2005. Some equipment used for assisting people were being used and their was no evidence that staff had received training in this area. People using he service also had issues with drug misuse and the staff team did not appear competent in this area. The manager was good at gathering literature to inform the team of the way various disabilities expressed themselves. Staff appeared competent and knowledgeable in meeting the needs of people who use the service. People spoken to said, “the staff are nice and friendly”. The number of staff employed in the home appeared insufficient to meet the needs of people using the service. Rotas inspected suggested that when staff were off sick the manager had to work on shift to ensure care is delivered to people using the service in addition to her other duties. The rotas showed that shifts were split in two starting from 7 am to 4 pm and 3:30 pm to 11pm. In addition to this a Sleep in staff was provided. Staff spoken to said they received regular supervision and support. Records seen suggested this happened on average of 6 weekly. Written evidence seen suggested staff had opportunities for meetings to discuss the development of people using the service. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38,39 &42. People who use the service experience an adequate quality outcome in this area. We have made this judgment using a range of evidence to include a visit to the service. The newly appointed registered manager have brought effective leadership to the home that have benefited people using the service, however further development is needed to ensure people using the service are safeguarded from scalds, as a result people could be at risk. EVIDENCE: The manager came into post in June 2007. She has embarked on her NVQ level 4 and RMA qualification. She currently manages two residential homes for Advance support that are in close proximity to each other. She explained how she shared the administrative responsibilities and the time spent in the homes are proportionate to the needs of the home. She said she was able to do so effectively, giving each home to attention and leadership required. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 23 Staff spoken to said, “The manager is very good she operates an open door policy”. Staff also commented that they have seen a vast improvement in the past months. The manager has been proactive in several aspects of the home and the recorded evidence suggests that people’s best interests were identified as an area to be was monitored. The quality assurance procedures have been reviewed and as a result questionnaires were designed to seek the views of people using the service. Some questionnaires were completed which suggested peoples views were sought about the service delivery. The home had not analysed these findings and as a result it was not clear how peoples concerns were actioned. We saw evidence to suggest people had regular residents meetings but again the request and concerns highlighted to be dealt with could not be evidenced. Procedures were in place for several aspects of health and safety. Fires records inspected suggested they were satisfactorily maintained. It was concerning however to note that the hot water temperatures mentioned in the environmental section of the report, could compromise peoples safety in the home. On the day of the inspection maintenance engineer arrived at the home to regulate the boiler which should lower the temperatures in the taps. Staff said this have already been done but the water still gets hot without any intervention and so it was not possible to avoid people getting burnt using the current measures. We also observed that several bedroom and communal doors were dropped open, which were not in accordance to the fire risk assessment of the home. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 3 4 X 5 3 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 2 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 2 X X 1 x Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 25 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 YA2 Regulation 14 (1) Requirement Timescale for action 30/10/08 2 YA6 3 YA7 4 5 YA7 YA17 6 YA24 7 YA33 8 YA35 All people using the service must a comprehensive assessment undertaken to ensure the holistic needs are identified at the onset of the care to be delivered. 15 (1) All care plans must clearly identify the care intervention required to ensure consistent service delivery. 13(4) (c ) All areas of risk identified in the care plan documentation and other wise must be risk assessed. 13 (4) All risk assessments must clearly show the level of risk posed to the person. 13 (4) (a) Arrangements must be made to ensure the safe storage and labelling of foods are implemented within the home. 13 ( 4) Temperature control valves must (a) be installed on all hot water taps in the home to protect people from burns and scalds. 18 (1) (a) Arrangements must be made to ensure sufficient staff are available to enable the manager to only work supernumerary to the team. 18 (1) (c ) Arrangements must be made to DS0000014989.V371845.R01.S.doc 30/10/08 30/10/08 30/10/08 30/10/08 15/09/08 30/10/08 30/11/08 Page 26 Ashburnham Road, 95 Version 5.2 (i) 9 YA39 24 (1) 10 YA42 23 (4) (a) ensure all staff receive specialist training to include mental health and drug misuse awareness. Systems must be in place to ensure the views of people are analysed and published in accordance with quality assurance procedures. The fire authorities must be consulted about alternative methods of keeping doors propped open. 30/11/08 30/10/08 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 YA6 Good Practice Recommendations Arrangements should be made to ensure all care plans are reviewed on a regular basis thatl reflect the changing needs of people using the service. Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Ashburnham Road, 95 DS0000014989.V371845.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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