CARE HOME ADULTS 18-65
Augusta Close (5 & 6) Parnwell, Peterborough PE1 5NJ Lead Inspector
Lesley Richardson Key Unannounced Inspection 15th May 2006 10:00 Augusta Close (5 & 6) DS0000015142.V291854.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 Augusta Close (5 & 6) DS0000015142.V291854.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. Augusta Close (5 & 6) DS0000015142.V291854.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Augusta Close (5 & 6) Address Parnwell, Peterborough PE1 5NJ 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) 01733 890889 Mr Alan Atchison To be appointed Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Augusta Close (5 & 6) DS0000015142.V291854.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 24th February 2006 Brief Description of the Service: Augusta Close consists of 2 properties, situated on a residential estate on the north eastern edge of Peterborough. Both houses are two-storey, detached properties in the same road. They are owned by Mr Alan Atchison and provide care and support for up to 9 people with learning disability. Fees for the home range between £335 and £520 per week. 5 Augusta Close has 4 bedrooms and 6 Augusta Close has 5 bedrooms, both houses have a lounge/dining room, kitchen, bathrooms with shower and toilet and a separate toilet. The houses share access to a large back garden with patio and lawn. The houses are within walking distance of local shops, pubs, a post-office and public transport. Peterborough city centre is about 5 miles away and is easily accessed by public transport. Augusta Close (5 & 6) DS0000015142.V291854.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over 7 hours and was carried out as an unannounced inspection on 15th May 2006 and 23rd May 2006. It was the first key inspection for this home for the 2006-2007 year. The lead inspector and a second inspector attended the first part of the inspection on 15th May 2006. 4 hours were spent with staff members, service users and undertaking a tour of the home. Not all of the people who live at the home were present during the inspection. The inspectors had conversations with five of the people who live at the home. The home is currently without the registered manager. The first part of the inspection visit was conducted with the manager from another home, which is run by the same provider. The provider was present for the second visit. Inspection comment cards from nine were received prior to the inspection and have been included in this report. Eleven requirements and ten recommendations have been made as a result of this inspection. Some of these requirements have been carried over from the last inspection as they have not been met. What the service does well:
The home provides a relaxed atmosphere for people living there and continues to offer personal care to service users living there. Prospective service users are able to visit the home for longer and longer periods of time to make sure they want to live there and they will get on with other people living at the home. People who live at the home are able to maintain relationships they form and continue seeing family either at the home or elsewhere. They can see people in private in the home and are able to maintain privacy when they are out of the home. Individual food preferences are respected and people who live at the home have the opportunity to cook meals for themselves if they wish. There is a wide range of activities inside and outside the home available to service users. Activities take place within areas used by the local community, such as swimming pools and cinemas, or those used by other people with learning disability. The family and relatives of people who live at the home are included in their lives. In a survey conducted by the Commission for Social Care Inspection service users said they could have visitors in private. Personal care given to people who live at the home is given in private and in a way that they wish. Staff are polite and respect individual’s right to privacy and their own space. People who live at the home are able to obtain advice from health care professionals either with a staff member present for support or alone if that is their wish.
Augusta Close (5 & 6) DS0000015142.V291854.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better:
Although there has been a little improvement, there are still a number of areas the home must improve to make sure they meet all the standards and regulations, and bring them up to an acceptable standard. Some of the information given to people who want to live at the home must be updated. When prospective residents visit the home a record must be kept of the visit. This shows how that person gets along with other people who live there and whether the home will be able to meet the new person’s needs. Care records kept to guide staff in how they can best meet the needs of people who live there must improve. They must show how the home intends to reduce the risks associated with activities, such as having access to a cooker or cleaning equipment and travelling on public transport or outside the home. Plans must be written to show staff exactly what they need to do to assist the person, but they must also show an outcome; if the person is able to carry out the activity with the support given or needs more help. Although the environment of the home has improved and there has been considerable renovation and decoration at the home, there are areas where the home should improve to make sure this remains the case. A programme of routine checks and maintenance should be started to identify and quickly put right anything that needs repairing or replacing. Staff training must improve as this has an effect on how well people who live there are looked after and how safe they are. New employees are given health and safety training but this is in the form of video presentation followed by a questionnaire. The questionnaires seen in one person’s file were not all completed and had not been checked. Not all health and safety training is updated on a regular basis and some training, such as food hygiene, is not given at all. Inadequate training in such areas as infection control not only leads to a lack of staff understanding about why soap and towels should only be used by one person but also places the people who live at the home at risk. Medication training by an appropriately qualified professional must be given to
Augusta Close (5 & 6) DS0000015142.V291854.R01.S.doc Version 5.1 Page 7 make sure medication is given correctly and the staff have proper understanding of what to do if something does go wrong. Although staff members have had training in protecting people from abuse, this doesn’t cover issues such as basic accounting. As there have been ongoing issues surrounding the accuracy of records for money kept on behalf of people who live at the home, training in basic skills should be given to staff with the responsibility for looking after this money. Not everyone living at the home feels they can raise concerns or complain about their care, although the majority of people who live there feel they can and are happy with the overall care. Although the home has asked the people who live there, their relatives and friends, and health care professionals about their views of the home, there is little that has come from this information. These views must go on to develop and improve the home for the people who live there, otherwise there is little to suggest it is anything more than an information gathering exercise. 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. Augusta Close (5 & 6) DS0000015142.V291854.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 Augusta Close (5 & 6) DS0000015142.V291854.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, 4 and 5 The outcome for these standards is adequate. Service users have most of the information they need to make an informed choice about where they want to live. EVIDENCE: There has been one service user admitted to the home this year. The home obtained an assessment from the placing authority prior to the service user’s admission but there is no evidence that they conducted their own assessment, or identified any possible difficulties the new service user and people already living at the home may have. The deputy manager said this service user had visited the home before moving in to see if he would like to live there. Notes from a meeting, held three days before admission, to plan the admission suggest the decision had already been made and the meeting was to identify the service user’s needs. Service users confirmed at a previous inspection that the new service user had visited the home prior to admission. A contract, signed by the service user, was seen on file. However, a current name and address of the Commission for Social Care Inspection was not included. Instead, there were references to a previous registration authority, an address, and Acts and regulations of parliament that suggest the contract has not been reviewed or updated for at least four years. Augusta Close (5 & 6) DS0000015142.V291854.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, 7, 8 and 9 The outcome for these standards is poor. There has been no improvement in the care planning system, which continues to provide inadequate information for staff to satisfactorily meet service users needs. EVIDENCE: The home has two files that provide information about how to care for service users. One file that contains mostly older reports and archived material, a folder that contains up to date information. Information about what each service user would like is provided in the document, ‘My Support Plan’. This is generally written in the first person, although there are areas that suggest this may not be the service users own words and areas that are written in the third person. There is nothing to show service user involvement with the document. The care records for four service users were looked at in detail. Care records do not properly show how staff should care for people living at the home, because identified needs do not have a plan that guides staff in what actions they need to take in order to meet that need. For example, one service user uses a motorised scooter because of reduced mobility, and another service user has an identified need regarding relationships. There are no plans to show staff what action they must take to meet these needs. There
Augusta Close (5 & 6) DS0000015142.V291854.R01.S.doc Version 5.1 Page 11 are no risk assessments to show how service users are able to take responsible risk, although clearly risk is taken as some often travel independently, attend day services without accompaniment of staff, and cook and clean in the home. Similarly, care records do not identify instances where service users rights have been limited through the assessment process. One service user had requested her door be fitted with a lock, although this was declined on the grounds of a health issue. However, both doors between the service user and sleeping night staff are closed during the night and there is no evidence to support concern regarding the health issue. This service user’s right to make the decision whether to have a lock on her door has been limited but not through the assessment process. Although the care records do not accurately show how care is being delivered to service users or whether this is the appropriate care for each service user. Responses to a survey sent out to service users showed that eight out of the nine service users at the home were happy with the overall care they receive. Augusta Close (5 & 6) DS0000015142.V291854.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, 13, 15, 16 and 17 The outcome for these standards is good. Social activities provide stimulation and opportunities for community links for people living in the home. Visits from relatives and friends ensure continued social contact. EVIDENCE: Service users access day placement, workshop activities, or employment during the day. They participate in activities, such as computer courses and tai-chi, at local venues, and attend clubs and entertainment venues aimed at the local community and their peer group. Service users said they liked going out to day placements and activities. Staff members interact with service users in a polite way, keeping in mind service users wishes and when they would rather be alone. Service users are able to go to their rooms alone and their movement around the home is not restricted. Service users said they are able to see who they wish, and have friends to visit and stay if they wish. Many service users have locks on their room doors, although a request made by one person for a lock was declined by the home because of possible health reasons, and this is discussed in the previous section.
Augusta Close (5 & 6) DS0000015142.V291854.R01.S.doc Version 5.1 Page 13 Information is available in care records about who service users have familial and social relationships with. However, there is no information or plan in care plans or review reports that informs staff how to enable service users to maintain that contact or guide them if relationships break down. One service user said she visits family at weekends, another service user said she no longer had many visits from her remaining family but was in contact by letter. Service users also said they had plans to go on holiday, either with other people living at the home or with friends. Participation in housekeeping tasks ensures service users are able to maintain skills and responsibilities for their home. Service users accompany staff members on shopping trips and they help with food preparation. There is no restriction on the availability of food and service users are able to make their own drinks and snacks when they wish. Service users were preparing the evening meal during the inspection. This included non-meat sausages, which were cooked separately to the other sausages. Records detailing food that service users are given do not give enough information to show whether the diet is satisfactory. However, as no service users have restricted diets a requirement has not been made on this occasion. Augusta Close (5 & 6) DS0000015142.V291854.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): 18, 19 and 20 The outcome for these standards is adequate. The systems for the administration of medication must improve to ensure service users are not at risk. EVIDENCE: A requirement was made at the last two inspections that staff who administer medication should receive appropriate training. However, there is still no evidence that more than one staff member has received such training. New staff members are given training by senior staff before they are able to administer medication to service users. This is the only training most staff members have received on medication and it is not enough to ensure service user safety. Concern was raised at the last inspection about medication being dispensed into disposable pots for and then taken to service users without reference to medication administration record (MAR) sheets. The home has now labelled these disposable pots with service users names, but continues to dispense without reference to the MAR sheets at the point of administration. This remains unsafe practice and must be improved. Staff members interact with service users in a positive way, asking if they would like to participate in personal care activities, but respecting their wishes
Augusta Close (5 & 6) DS0000015142.V291854.R01.S.doc Version 5.1 Page 15 if they decline. Care records show service users have access to a variety of health care professionals to ensure these needs are met and comments made by service users confirmed this. Augusta Close (5 & 6) DS0000015142.V291854.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): 22 and 23 The outcome for these standards is adequate. Systems in the home do not guarantee all service users feel their concerns are listened to or ensure their financial safety. EVIDENCE: Information supplied to the Commission for Social Care Inspection prior to the inspection shows they have received no complaints or protection from abuse investigations in the last twelve months. Staff members have policies and procedures that would give guidance about what to do in the event of a complaint or allegation of abuse. Nine service users comments were received on relatives/visitors forms before the inspection. Seven people said they were aware of the complaints procedure and seven said they had never had to make a complaint. However, one person said during the inspection that she didn’t feel able to make her concerns known to staff members. A service user made an allegation during the inspection of possible verbal abuse by staff members, although she could not give details. The service user asked for her concerns to be passed on to her care manager, and this was done. Improvement has been made in recording service users financial transactions, although inaccuracies are still occurring meaning some service users have less money than they should. Augusta Close (5 & 6) DS0000015142.V291854.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 The outcome for these standards is adequate. The standard of décor within this home has improved presenting as a homely and comfortable environment for service users. EVIDENCE: There has been considerable renovation work on both houses and most areas of concern that had previously been identified have been either repaired or replaced. However, there are two areas in the kitchen at no.6 Augusta Close that must be improved: the hole in the kitchen cupboard door and a drawer in a cupboard that had the front panel broken off. A bar of soap and a hand towel were found in a bathroom in no.5; communal use of soap and towels should not occur as this increases the risk of cross infection. A container of petrol and another of oil were stored in the conservatory at no.5, but were moved to a more appropriate location immediately. Therefore a requirement will not be made on this occasion. Both houses were generally clean and tidy on the day of inspection, décor is domestic in appearance and service users are comfortable with the layout. There were no offensive odours. The home should complete a routine maintenance assessment and programme to ensure it remains in a good state of repair.
Augusta Close (5 & 6) DS0000015142.V291854.R01.S.doc Version 5.1 Page 18 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 The outcome for these standards is poor. There has been little improvement in staff training opportunities, but further improvement is required for all staff to be able to meet the needs of service users. EVIDENCE: Information received prior to the inspection shows 50 of staff working at the home have a national vocational qualification (NVQ) in care at level 2 or above. This information also states staff have had training in protecting vulnerable people from abuse and fire awareness. A staff file showed health and safety training given during induction was in the form of video presentation and completion of a questionnaire following this. However, the questionnaires had not been marked, there were a number of questions unanswered and some answered incorrectly. This form of training gives the staff member little or no opportunity to practice what is being taught (as in First Aid) or to ask questions. Fire awareness was seen in one person’s file, but food hygiene training was not seen in any of the three staff files seen. There is little evidence to show staff members have had updated health and safety training or that all staff with responsibility for medication administration have had appropriate training. A staff rota supplied to the Commission for Social Care Inspection for four weeks over the months of April and May still does not show clearly the hours worked by staff members. The rota supplied shows staff shifts covering the
Augusta Close (5 & 6) DS0000015142.V291854.R01.S.doc Version 5.1 Page 19 hours of 8am to 11pm each day but does not show which staff member covers the sleeping night shift. Only one of the staff files contained supervision notes. Augusta Close (5 & 6) DS0000015142.V291854.R01.S.doc Version 5.1 Page 20 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, 38, 39 and 42 The outcome for these standards is poor. There has been some improvement in the systems for service user consultation but as yet no evidence that service user views are acted upon within the home. EVIDENCE: The home has been without a registered manager since the beginning of April 2006, although arrangements have been made to ensure continued management structure and the owner is acting as manager until a new manager is appointed. A quality assurance survey was conducted in March ’06 with questionnaires returned by service users, health professionals, and service users friends and families. An assessment has been made of the responses from health professionals, friends and families, but not of responses from service users. There is no development plan for the home following the survey or a report to show how the home plans to improve. Augusta Close (5 & 6) DS0000015142.V291854.R01.S.doc Version 5.1 Page 21 A service user who has expressed an interest in the task completes hot water temperature checks and fridge/freezer temperature checks. Staff must be sure the service user has appropriate guidance and training to perform the tasks correctly. Training records indicate none of the staff members have had all of the mandatory health and safety training or updates. This must improve to ensure staff and service users are safe. Augusta Close (5 & 6) DS0000015142.V291854.R01.S.doc Version 5.1 Page 22 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 2 2 1 3 X 4 3 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 2 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 2 1 X X 1 X Augusta Close (5 & 6) DS0000015142.V291854.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES 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 Requirement Timescale for action 20/07/06 2 YA7 12(2) 3 YA9 13(4)(b) 4 YA20 13(2) The registered person must prepare a written plan as to how the service user’s needs in respect of his health and welfare are to be met. The registered person must keep the service user’s plan under review. (Previous timescale of 15/04/06 not met.) The registered person must 20/07/06 enable service users to make decisions with respect to the care they are to receive and their health and welfare. The registered person must 20/07/06 ensure that any activities in which service users participate are so far as reasonable practicable free from hazards to their safety. (Previous timescale of 15/04/06 not met.) The registered person must 15/07/06 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (Previous timescales of 30/11/05 &
DS0000015142.V291854.R01.S.doc Version 5.1 Augusta Close (5 & 6) Page 24 15/04/06 not met.) 5 YA23 The registered person must make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. 13(3) The registered person must make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. 18(1)(c) The registered person must ensure that the persons employed to work at the care home receive training appropriate to the work they are to perform. A plan of scheduled training must be received by this date. 18(2) The registered person must ensure that persons working at the care home are appropriately supervised. Care Any person who carries on or Standards manages an establishment or Act 2000, agency of any description Section 11 without being registered under this Part in respect of it shall be guilty of an offence. 24(1)(a), The registered person must (b), (3) establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home. The system must provide for consultation with service users and their representatives. 13(3)(4)(5), The registered person must 16 make suitable arrangements to prevent infection and the spread of infection at the care home, for the training of staff in first aid, and to provide a safe system for moving and handling service users.
DS0000015142.V291854.R01.S.doc 13(6) 31/07/06 6 YA30 15/07/06 7 YA35 15/07/06 8 YA36 31/07/06 9 *RQN 31/08/06 10 YA39 31/07/06 11 YA42 31/07/06 Augusta Close (5 & 6) Version 5.1 Page 25 (Previous timescale of 31/03/06 not met.) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA1 YA2 Good Practice Recommendations The contract should be updated to reflect current information. The home should conduct its own pre-admission assessment of service users and document any contact it has with prospective service users to identify needs and how that service user will interact with existing service users. Service users care plans should be reviewed on a 6 monthly, or more frequent, basis. Instances when service users’ rights are limited and the reasons for this should be recorded. Records detailing food provided to service users should specify alternatives given to those service users not eating the main meal. The home should ensure all service users have the opportunity to make their concerns or complaints known. A programme of routine checks and maintenance should be commenced to identify and resolve environmental deterioration quickly. Staffing rotas should clearly identify shift hours and which member of staff is working on each shift. A staff training programme should be developed to ensure all staff receive training appropriate to the work they are to perform. Any person within the home performing health and safety checks should be assessed to ensure they have the knowledge and competence to properly carry out the role. 3 4 5 6 7 8 9 10 YA6 YA7 YA17 YA22 YA24 YA33 YA35 YA42 Augusta Close (5 & 6) DS0000015142.V291854.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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