CARE HOME ADULTS 18-65
Augusta Close (5 & 6) Parnwell, Peterborough PE1 5NJ Lead Inspector
Lesley Richardson Key Unannounced Inspection 21st November 2006 11:15 Augusta Close (5 & 6) DS0000015142.V321711.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 Augusta Close (5 & 6) DS0000015142.V321711.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. Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 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 Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th May 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.V321711.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over 3½ hours and was carried out as an unannounced inspection on 21st November 2006 by the lead inspector and another regulation inspector. It was the second key inspection for this home for the 2006-2007. 2½ hours were spent with staff members, service users and undertaking a tour of the home. The inspection was conducted without the manager present. Two random inspections and a specialist pharmacist inspection have taken place since the last key inspection, these are commented on in this report. 11 requirements and 6 recommendations have been made as a result of this inspection. 3 of these requirements have been carried over from the last inspection. What the service does well: What has improved since the last inspection?
There has been a significant improvement in the information contained in the care records, with some people writing their own support plan. This tells staff members what help that person needs and how they would like to receive that help to live their life. Risk assessments are completed to show why particular activities, like going to day activities on public transport alone, are a risk and what staff members need to do to lower the risk. There has been some improvement in the way the home handles medication, although more improvement is still needed to make this a completely safe activity. Improvements still needed are described in the section below.
Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 Page 6 There are policies and procedures to guide staff if they receive a complaint or think people who live at the home may have suffered abuse. Care records for the people who live at the home show they have told staff about concerns and what action has been taken about them. The home has made two referrals to the local adult protection team, and put into practice the advice given on how to deal with the situations. The amount of staff training that is available has improved, and staff members said they have attended training sessions on medication administration and protection from abuse, as well as required health and safety training. Staff files were looked at during one of the random inspections between this and the last key inspection. The way the home makes checks and obtains information before a new staff member starts working has improved, which means people who live at the home are safer. Staff members are now being given supervision on a regular basis, which means they have proper support. The home has a new manager who has made improvements to the way the home is run, but the manager must register with the Commission for Social Care Inspection. What they could do better:
Although there have been a number of improvements at the home, there are still more improvements that need to be made to make sure the home meets all the National Minimum Standards and Care Homes Regulations 2001. The home does not have any guidance for staff when prospective residents visit the home. An assessment is obtained from social care professionals but the home does not visit people to carry out their own assessment. Although prospective residents visit the home before they move in, the home should carry out an assessment of their own so that they can be sure the new resident will get on with other people living there. Accurate records must be kept about the food people eat; at the moment records show people who do not eat meat only eat of some days of the week. Some of the issues about medication have been improved upon, although there are two areas where more improvement is needed. Staff take temperature checks of medication storage areas but they don’t record these, and this must be done. When people who live at the home agree for staff to given them their medication, this agreement must be recorded and kept in residents’ files. Although both houses have had some redecoration and renovation work in the last year there are quite a few areas that need more attention. The kitchens and bathrooms in both houses need cleaning, repairs or replacement, and bedrooms in one house need repairs and furniture replacing. The garden at the back of both houses is not safe and must have safety measures, like Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 Page 7 lighting and rails. The paving in the garden should also be re-laid to make sure people are safe when walking between the two houses. A quality assurance survey was completed in March this year (2006), but an action plan to show how the results would improve the home has not been developed. This must be done if the home is to develop and run in the way people who live there would like. Health and safety checks show hot water temperatures are too hot for water coming out of the tap. Staff members were not sure where hot water temperatures must be taken or what temperature they should be looking for which location. They must contact the proper health and safety authority for up to date advice. 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. Augusta Close (5 & 6) DS0000015142.V321711.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 Augusta Close (5 & 6) DS0000015142.V321711.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): 2 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is no guidance for staff to assessment prospective service users, therefore being unable to ensure they will be able to meet that person’s needs. EVIDENCE: The home does not have an pre-admission policy or procedure to guide staff in the best way to assess prospective service users. A pre-admission assessment is obtained from the placing authority, although the home does not complete its own assessment of needs. Staff said prospective service users are able to visit the home for increasing amounts of time until they are able to decide whether they want to live at the home or not. An admission policy and procedure is available for staff to follow once a service user has been admitted to the home, but this is quite task orientated and formal, and is not dated, which does not show whether it is current or not. No new service users have been admitted to the home since the last inspection. Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Progress has been made on improving arrangements for the personal and health care needs of service users to be identified and met, thereby ensuring service users receive appropriate care. EVIDENCE: Each person at the home has an individual care plan, and a support plan, which some service users have written. Everyone is consulted about their support plan and sign the document to say they are happy with it. The information in care records has improved since the last key inspection and now contains more detailed information, identifies needs and has actions for staff members to complete to ensure each need is met. All care plans except one have been reviewed by the home in the last 6 months. Not all care records are signed and dated, and this should be completed when an entry is made to ensure there is an audit trail.
Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 Page 11 Assessments are completed for areas where there is an associated risk. For example, one person now has management plans for eight different activities or situations he may find himself in. These identify the risk and how it should be managed to avoid the service user putting himself at an unacceptable level of risk. Service users are supported to make decisions about their own lives. If those decisions go against medical advice, such as smoking, the decision to continue with the activity is assessed for risk and agreements are made so that person is as safe as possible. One person has asked that she be able to write information to be included in the review of her care plan, and staff have arranged specific time with her to do this. Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Social activities provide stimulation and opportunities for community links for people living in the home. Visits from relatives and friends ensure continued social contact. Dietary records are not detailed enough to show all service users are eating a balanced diet. 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 present during the inspection interacted with the one service user at home in a polite way, keeping in mind her wishes and when she
Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 Page 13 wanted to be alone. Service users are able to see who they wish, and have friends to visit and stay if they wish. Some people have locks on their room doors, although there was no information in care records to show this had been discussed with all service users or their feelings about having a lock or not. Information is available in care records about who service users have familial and social relationships with. One service user said she visits family at weekends. 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 take turns to prepare the evening meal for the house they live in. Meals include vegetarian options, which are cooked separately if the main meal is not vegetarian. There has been a little improvement in recording of food provided, although there are still days where no vegetarian alternative is shown and no indication of which service users eat the alternative meal. Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvement has been made to the systems for medication administration, storage and staff knowledge. This ensures a greater degree of safety but must improve further for service users to be completely safe. EVIDENCE: Although it was not possible to fully assess staff interaction with service users during the inspection, the interaction seen was positive and engaging. 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. A specialist pharmacist inspection was conducted in August 2006 and six requirements were made as a result. There have been some improvements to the systems at the home for medication, although not all requirements have been met. Medication is now kept in each house and staff members take medication to service users rather than having service users go to the office. All but one new member of staff has completed medication training, and this
Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 Page 15 staff member does not have this responsibility. Staff said consent had been obtained from service users for medication to be administered to them, and apart from an indication in some of the support plans that staff need to administer medication, there was no documentation to show this. Medication administration records (MAR) indicated medication had been correctly given and signed for, although as these records had only been started a few days prior to the inspection this will be looked at again to ensure staff continue to record correctly. One person identified at the pharmacist inspection as selfmedicating to a limited extent has a risk assessment on file for this. However, although the risk assessment indicates the person is not able to self-medicate he continues to do so in a limited way. There was no information to show he can safely continue to use this medication without assistance and supervision. Staff said temperature checks are made of the medicine storage areas in both houses, although this is not recorded. There must be further improvement in the risk assessment of medication and the records surrounding them to ensure service users are safe and their rights are not infringed. Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have been made to procedures for complaints and safeguarding adults, which ensures service users are able raise concerns and have these acted on. EVIDENCE: The home has a logbook for recording verbal complaints, although there have been none since the last inspection. There have also been no written complaints since the last inspection. There is evidence in service user care records to show service users are able to raise concerns and have them responded to. There is a policy and procedure that guides staff in how to protect service users from abuse and what to do if they suspect this may have occurred. All staff members have completed training given by the local Adult Protection team. Two referrals have been made to the Adult Protection Team since the last inspection; these were reported and dealt with correctly. Improvement has been made to records kept for service users money and shows 3 people in each house prefer staff to manage their money for them. Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although improvements have been made to the home, there are a number of matters that put service users at risk of serious harm and do not provide safe and pleasant surroundings in which to live. EVIDENCE: Although recent improvements have been made to both houses, further work needs to be carried out to ensure service users live in a safe and comfortable environment. Staff complete weekly health and safety checks and issues of concern are identified. Issues identified at this inspection are: No.6 • Mould and mildew on ceiling and walls, around the bath and on the blind and shower curtain. If staff members provide support to service users to
Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 Page 18 clean communal areas of the home, there should be a system of review to ensure this is completed appropriately to prevent mould and mildew build up. • Service users rooms; one person needs a new bed, new carpet and room redecoration, another person has a broken blind and plaster work above the bed that requires repair. Service users have previously been required to pay for new bedroom furniture, such as beds. This must not happen again as the home has a duty to provide this furniture. Not all service users rooms were assessed, but this should not mean these are the only rooms were furniture is replaced if needed. • Hole in kitchen cupboard door must be repaired. This was identified at inspections on 15th May 2006 and 24th February 2006. • This house has no tumble dryer and service users are reliant on drying garments over radiators or taking wet clothing and bedding to No.5 if they wish to use a tumble dryer. A tumble dryer should be provided for this house. No.5 • Ground floor shower covered in lime scale, there is no power and no temperature control on the shower. • Ground floor toilet seat cracked. • Kitchen cupboards need replacing. Exterior • Paving between houses needs to be re-laid. • An external light is needed between the two houses. • Rails are needed on exit doors to both houses; both houses have a step up to the front doors and a step into the houses, and steps out of conservatory doors at the rear of the property are very high. There is at least one service user in each house with identified mobility needs where these steps make independent access and entry more difficult and unsafe. Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvement to staff training ensures staff have greater knowledge and understanding in how to meet service users needs and keep them safe. Further improvement is required to ensure staff fully benefit from supervision and are supported. EVIDENCE: It was not possible to fully assess this outcome area as the staff on duty during the inspection did not have access to staff files. Staff members said training opportunities had improved since the last inspection, and as mentioned in other areas of this report, training has been given in medication administration and protection from abuse, and other areas of health and safety training. A training matrix is available but this had not bee updated to included recent training. A new member of staff said he has received no training since being employed to work at the home, although he
Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 Page 20 had undertaken mandatory health and safety training with his previous employer. Staff members said they had been given supervision sessions on a monthly to 6 weekly basis. Although they also said there was little support for staff after hours in the event of an emergency. If difficulties occur over a weekend, for example, the person working at the home would contact another colleague working the same weekend, for advice rather than a senior staff member. Staff recruitment files were not available for assessment on this occasion. However, assessment has taken place during a random inspection between the last key inspection and this key inspection. Improvement had been made to the recruitment and vetting checks the home completes for new staff members, and the requirement had been met. Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there has been an improvement in how service users’ views have been sought, further improvement is required to ensure the results affect how the home is run. EVIDENCE: A manager has been employed to work at the home since September 2006. An application to register with the Commission for Social Care Inspection (CSCI) has not yet been submitted, and staff say the manager is not at the home on a day to day basis, although he can be contacted by telephone and messages can be left if he is not immediately available. An application to register the manager with CSCI must be submitted.
Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 Page 22 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. This has not changed since the last inspection; no action plan has been developed to show how the home plans to improve, or how it plans to resolve issues raised by service users. Residents meetings are now taking place more frequently, minutes were seen for meetings held in July and October 2006. Staff undertake weekly health and safety checks for specific areas in each house, with the aim of identifying any issues that need attention. Hot water checks were seen, with upper temperatures of 50oc. Maximum hot water temperatures were discussed with staff, who were of the opinion that to prevent Legionella hot water temperatures should be 50oc. However, the inspectors felt this was water leaving the boiler, not water leaving taps. Staff were told they must check with Environmental Health Department to ascertain correct temperatures for different areas. Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 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 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 1 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 2 X 2 X 2 X X 2 X Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 Page 24 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 YA17 Regulation 17(2) Requirement Timescale for action 31/12/06 2 YA20 13(2) 3 YA20 13(2) 4 YA20 13(2) The registered person must maintain in the care home the records specified in Schedule 4. Records of the food provided for service users must be kept in sufficient detail to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service users. The registered person must 21/11/06 ensure that staff adhere to the policy and procedures for the safe handling and administration of medicines. (This standard was not assessed on this occasion.) The registered person must 15/12/06 ensure that the temperatures of the medicines storage areas are monitored and recorded. (Previous timescale of 15/09/06 not met.) The registered person must 31/12/06 ensure that consent to treatment is obtained and retained on file. (Previous timescale of 30/09/06 not
DS0000015142.V321711.R01.S.doc Version 5.2 Augusta Close (5 & 6) Page 25 met.) 5 YA24 23(2)(a) The registered person must ensure that the physical design and layout of the premises meet the needs of the service users. 23(2)(b) The registered person must ensure that the premises are kept in a good state of repair externally and internally. 16(2)(c) The registered person must provide in rooms occupied by service users adequate furniture, bedding and other furnishings, including curtains and floor coverings. 13(3) The registered person must make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. Care Any person who carries on or Standards Act manages an establishment or 2000, section agency of any description 11 without being registered shall be guilty of an offence. The manager must submit an application to register with the Commission for Social Care Inspection. 24(1)(a), (b), The registered person must (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. (Previous timescale of 23/08/06 not met.) 13(4)(a) The registered person must ensure that all parts of the home to which service users have access are free from hazards to their safety. The appropriate authority must be contacted for correct advice
DS0000015142.V321711.R01.S.doc 31/03/07 6 YA24 31/03/07 7 YA26 31/12/06 8 YA30 31/12/06 9 RQN 31/12/06 10 YA39 21/11/06 11 YA42 15/12/06 Augusta Close (5 & 6) Version 5.2 Page 26 about hot water checks. 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. Written policy and procedures for the safe handling of medicines should be signed and dated to indicate they are current. Staffing rotas should clearly identify shift hours and which member of staff is working on each shift. The training matrix should be updated to accurately show when training has taken place. Staff should have senior management support at all times. 3 4 5 6 YA20 YA33 YA35 YA36 Augusta Close (5 & 6) DS0000015142.V321711.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office 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
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