CARE HOMES FOR OLDER PEOPLE
Autumn Care 41 Dudsbury Road Ferndown Dorset BH22 8RB Lead Inspector
Jo Palmer Announced Inspection 10:00 13 October 2005
th X10015.doc Version 1.40 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 Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 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 Older People. 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. Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Autumn Care Address 41 Dudsbury Road Ferndown Dorset BH22 8RB 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) 01202 573746 01202 573746 Mr John Henry Hughes Mrs Susan Linda Hughes Mrs Debra Eve Barbara Dacey Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 30th June 2005 Brief Description of the Service: Autumn Care, formerly Dudsbury Manor, is registered with the Commission for Social Care inspection to accommodate a maximum of 14 older people. Mr & Mrs Hughes own the home and Ms Debra Dacey is the registered manager. The premises are located in a residential area a short drive from the centre of Ferndown. Local amenities including shops and a pub are available within walking distance. A bus service is available nearby. The home is a converted and extended family home with bedrooms on the ground and first floor levels. There are ten single rooms, eight of which have en-suites and two shared rooms; both shared and two singles are on the ground floor. A stair lift provides access between floors. A communal dining room and lounge is on the ground floor. The gardens are well maintained and there is outside seating to the rear of the home. Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection on 13th October 2005 lasted for four hours. Ms Debra Dacey, the registered manager was present throughout and provided necessary information and access to records, Mr & Mrs Hughes were also both present for part of the inspection visit. The purpose of this inspection visit was to monitor progress in addressing requirements of the last inspection and to review practices in relation to some of the National Minimum Standards. This was a positive inspection where it was noted that significant progress has been made in improving the care and services and where it has been identified that of the National Minimum Standards assessed, many have been, or are in the process of being met. The inspector spoke with six residents, one care assistant, the manager and Mr & Mrs Hughes, toured the premises and examined relevant records. The commission sent comment cards to the home to be provided to relevant persons to obtain their views on Autumn Care, at the time of writing the report the following had been returned: • • • • 3 4 1 2 from residents from relatives and visitors to the home returns from a GP from other health and social care professionals. Comments from these are included in the next sections of this report. What the service does well:
Two of the three residents who responded to comment cards confirmed that they like living in the home, feel well cared for and are treated well by staff, both confirmed that their privacy is respected, all three confirmed that they like the food and that they feel safe in the home. Two respondents think there are sometimes sufficient activities, one thinks there is not and all three confirmed that they would know who to speak to if they had any concerns about their care. Relatives responded to comment cards by confirming that all are made to feel welcome, they can visit their relative in private, they are kept informed of important matters and that there are always sufficient numbers of staff on duty. All respondents confirmed they are aware of the home’s complaints procedure although none had ever had to make a complaint. Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 6 One comment card returned from a GP and two from other health care professionals who visit residents at the home responded positively to questions posed about communication with the home, staff understanding of people’s needs, medication management and specialist advice being incorporated into the resident’s care plan. One additional comment received complimented the recent decoration and refurbishment, stated that staff are kind and attentive and that residents are happy. Of the National Minimum Standards inspected, the following was identified during this inspection: Residents are provided with sufficient information and have a needs assessment prior to moving to the home; this enables them to make an informed decision as to whether Autumn Care is the best place for them before committing to a contractual arrangement regarding their stay. Staff are provided with clear instruction in care plans regarding how individual resident care needs are to be met. It was evident that residents are consulted with regard to their care and that they agree with care outcomes. Residents spoken with confirmed that a kind and caring staff group treat them respectfully. Social care is limited although most residents confirmed they are happy in organising their own time in the home, some aspects of care planning addresses peoples social and recreational needs although these need to be more individual and based on residents preferences. Family and friends are able to visit at any time with no restrictions. Meals provided at the home are well received, residents spoken with confirmed that there is a variety of home cooked meals available with an alternative should they prefer something other than the set meal. No complaints have been received by the home or the Commission in respect of services at Autumn Care, residents are provided with a written complaints procedure should they wish to raise concerns. Resident’s rights are supported by the home ensuring that each resident has support managing their affairs and residents are protected by procedures for managing nay allegations of abuse; there have been no allegations. The premises of Autumn Care have been substantially upgraded and refurbished since the last inspection, accommodation is now provided in a clean, safe, well-maintained environment where each resident has their own room, which they are able to personalise and spend time in as they please. Residents are provided with appropriate facilities for washing and bathing and there is pleasant communal space available. Sufficient numbers of staff are on duty during the day and night; all staff are recruited appropriately to ensure they are fit to work in a care environment and some staff training has been provided.
Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 7 Ms Dacey has been supported in managing the home by Mr & Mrs Hughes and between them, they have significantly improved the home’s administration and organisation. Records are well organised and held securely for the benefit of resident confidentiality and all records seen were well maintained, up to date and accurate. What has improved since the last inspection?
There were twenty-three requirements of the last inspection and the registered persons have worked hard and shown a commitment to ensuring that these requirements have been addressed. Nineteen of the requirements have been addressed and Mrs Hughes confirmed that the remaining four, which are repeated in this inspection report, would be addressed shortly. Four requirements were made concerning the admissions process including availability of information to residents and contracts, and the pre admission assessment process; this inspection evidenced that these issues have been addressed. Three requirements were made concerning the care and welfare of residents and how the home could demonstrate that their needs were being met. This inspection evidenced that the assessment, care planning and review process has improved and now sufficient instruction is available to staff to ensure they are aware of how assessed needs are to be met. Medication management issues were also raised as a result of the last inspection, this visit confirmed that systems for medication administration had been reviewed and safe practices were employed for the protection of residents. This inspection evidenced that residents are now consulted with regard to their assessment and care planning and those that are able are now able to confirm that they are involved in the process of identifying their care needs and social and leisure preferences. Three requirements were made concerning the homes complaints and protection procedures, policies have been reviewed and now provide procedural guidance for staff to follow in the event of any incidents being reported or complaints received. A record is also held on each residents file detailing their advocacy arrangements. Facilities are now available for staff hand washing in line with infection control procedures. Of five requirements made regarding staffing in the home, four had been addressed. There was a written duty rota demonstrating which staff were on duty at any given time, staff recruitment processes are more efficient for the protection of residents and residents records detail more clearly that staff
Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 8 understand their role in relation to specific issues or care needs. Further arrangements for staff training need to be established. Of six requirements made at the previous inspection concerning the home’s management arrangements and administration, three had been addressed. Staff now receive regular, formal supervision, records were held appropriately and were available for inspection and the fax number has been provided. What they could do better: 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. Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4. Standard 6 in not applicable The home’s Statement of Purpose and Service User Guide provide detailed information about the care and services provided at Autumn Care. The admissions process is such that it ensures resident’s needs are assessed prior to admission and that residents are assured these needs can be met by the home prior to signing a contract. EVIDENCE: A copy of the home’s Statement of Purpose and Service User Guide was examined, this has been reviewed following a requirement of the last inspection and now provides information about the care and service available at Autumn Care to prospective residents prior to their making a final decision to move to the home. An ‘admissions pack’ has been produced which contains all the necessary information for the purpose of admitting, assessing and making arrangements for a new person coming to the home including a contract detailing the terms and conditions of residency.
Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 11 Care files for two residents recently admitted to the home were examined. One of these demonstrated that a full, pre-admission assessment had been undertaken by staff of Autumn Care and that as a result of this assessment, it had been agreed between the manager and resident’s representative, that Autumn Care was a suitable placement for meeting the residents needs. The second resident whose file was examined was admitted under a care management arrangement, Ms Dacey ensured that needs assessment information was received at the home prior to the resident moving in to establish whether Autumn Care was a suitable placement. Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Care plans provide sufficient detail for staff to be aware of resident’s health and welfare needs and how to meet them; care needs are reviewed appropriately. Systems are in place for resident consultation and participation in the assessment and care planning process. Resident’s rights are respected and their right to privacy is supported through care delivery, relationships with staff and confidential record keeping practices. EVIDENCE: Care plans examined detail how resident’s needs are to be met in relation to personal care, elimination, mobility, diet, emotional needs and some social care. Instruction for staff in care plans is clear and details how each aspect of need is to be met, monitored and reviewed. Daily records are written by staff for each resident, these provided a detailed report of the resident’s daily routines, lifestyles and any significant health or welfare problems. Care plans and daily records are written in a manner that uses easy to understand language and is respectful of the resident’s needs and problems.
Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 13 A review of the home’s medication management systems demonstrated that policy and procedural guidance is followed and residents are protected by safe practice. Staff who have responsibility for handling medication in the home have received appropriate training. Residents spoken with that were able to comment confirmed that a kind and caring staff group treat them respectfully; staff and residents were observed in their interactions to have mutually respectful relationships. Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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, 14 & 15 Residents are able to benefit from self-determined activity as far as their health and general abilities allow; organised social care for those less able residents is limited. Residents are supported in maintaining contact with their friends and family and in making decisions about their lives in the home. Dietary needs of residents are well catered for with a balanced and varied selection of meals that meets their individual tastes and choices. EVIDENCE: Some residents spoken with confirmed that they felt their was sufficient stimulation in the home, they were able to make choices regarding how they spend their day which involved watching television, reading books, magazines etc and receiving visitors. Some residents, also able to make these decisions confirmed that there was not any real stimulation or activities available although this did not unduly concern them. Social care plans are available identifying to a limited extent how each resident spends their day although these are not base don an assessment of social and recreational preferences. However, Ms Dacey confirmed that relatives and residents have been approached and asked to provide a social history identifying their likes, dislikes, hobbies and interests in order that Autumn Care can provide more targeted social care programmes.
Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 15 Assessments and care plans provided evidence of consultation with the resident or their relative thereby indicating that they have been helped to exercise choice over their identified care outcomes. Residents spoken with confirmed that they are able to make decisions and choices in the home with regard to what time to get up, go to bed and how to spend their day. Daily records examined provided an account of each resident’s life in the home including any social activity and family and friends visits. Menus are available to residents each day; these demonstrate that a set meal is prepared for the main meal of the day although residents spoken with confirmed that alternatives were available. Residents spoken with confirmed that the food was always good and appetising. The midday meal was observed during this inspection, it was a relaxed affair with residents sat at pleasantly laid tables where a choice of red or white wine, a soft drink or water was offered. Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 Any person wishing to complain is directed through a written procedure detailing how their concerns will be addressed, they can therefore be confident that their complaints will be listened to and taken seriously. Resident’s rights are upheld through appropriate representation with their affairs. Procedures for responding to suspicions of abuse are held in accordance with Department of Health guidance, meaning that any allegations of abuse can be managed effectively. EVIDENCE: The home’s complaints procedure is contained in the Service User Guide and in contractual information provided for residents. Ms Dacey confirmed that no complaints have been received. A record is held in residents care files with information about their support systems and representatives whether they be the residents next of kin, a nominated power of attorney, firm of solicitors or care manager. Procedures are in place for staff guidance providing information on what to do if they suspect a resident is being abused or harmed in any way. A requirement of the last inspection had been addressed in part although discussion with Mrs Hughes during this inspection resulted in the need for further minor revision. Staff spoken with demonstrated an understanding of this guidance and it was noted that training relating to adult protection has been arranged for all staff in November 2005. There have been no reported incidents.
Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 Recent and ongoing investment has significantly improved the appearance of this home creating a comfortable and safe environment for those living there and visiting. The home is clean, hygienic and comfortable and sufficient space is provided for residents both privately and communally. EVIDENCE: There was evidence of substantial investment in the furnishings, décor and with some small structural changes to the premises during this inspection. Resident’s bedrooms provide sufficient space and communal areas including the lounge and dining room provide a pleasant environment for residents. All areas are appropriately furnished and most items are being replaced, resident’s bedrooms all have locks to secure the resident’s privacy but which allow for access by staff in the event of an emergency. Emergency call points are in each resident’s room, all areas are appropriately lit, heated and ventilated. Radiators have been guarded to prevent accidental scalding and hot water temperatures have been regulated. Bathrooms and toilets are conveniently sited around the home and eight single rooms benefit from ensuite facilities. The premises have not been assessed to establish the extent of
Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 18 the disability equipment needed although Ms Dacey confirmed that individual residents mobility needs would be assessed as required. Following a requirement of the last inspection, staff are provided with antibacterial soap and disposable towels use in accordance with infection control procedures. Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The deployment and number of available staff is sufficient to meet the needs of the residents. The arrangements for staff training must be improved although the registered persons have made efforts to achieve this. Ms Dacey is aware of the principles of good recruitment practice. EVIDENCE: Staff rota’s seen evidence the numbers of staff on duty but not in what capacity. It is recommended that staff roles be identified on the rota. Various shifts are worked at Autumn Care between 8.00am and 9.00pm and rotas demonstrate that there are three staff each morning, two each afternoon and evening and one at night with another member of staff sleeping in/on call. The night shift is between 9.00pm and 9.00am. Ms Dacey confirmed that all staff are due to commence NVQ level 2 training in January 2006. Other training is being organised to ensure staff remain up to date with basic practice in areas such as moving and handling, infection control, food hygiene, first aid etc. Not all staff have had up dates in these subjects. Other training sessions that were booked at the time of this inspection and arranged for November 2005 included short courses on Dementia Awareness and Elder Abuse. Staff recruitment records examined demonstrated that all required information was obtained prior to the person taking up post to ensure they were fit for the role.
Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 20 An induction training pack is available to new staff at Autumn Care that is written in a manner that adheres to requirements of National Occupational Standards for care staff. The methods of learning for staff are not measurable however, next to each area of learning, the staff member signs and dates although this does not indicate the extent of the learning or any form of assessment. There is no foundation training programme. Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 & 37 Management arrangements for the home have improved and the registered providers and manager are now working well together to improve the service at Autumn Care. Resident’s views are sought in relation to individual care requirements but they do not influence the general running of the home and the registered persons do not review aspects of performance through a programme of self-review and consultations, which include seeking the views of residents, staff and relatives. EVIDENCE: Ms Dacey confirmed that she has to complete one more unit to obtain the NVQ level 4 award, Ms Dacey hopes to achieve this by January 2006. Since the last inspection, Mr & Mrs Hughes have been more active in the management of the home and have reviewed many aspects of the administration and organisational practices and provided better support for Ms Dacey. It remains a
Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 22 requirement that Ms Dacey has a written job description outlining her role and responsibility. Although it was evident that Mrs Hughes has been providing support to Ms Dacey and has been actively involved in recent improvements, it remains a requirement that a monthly unannounced visit is undertaken and reported on to demonstrate that the registered providers are able to form an opinion of the standards of care provided in their home. Staff records examined evidenced that regular supervision of staff takes place formally to identify their training needs and discuss areas of practice. Recent reorganisation has ensured that resident’s care records, accident records, staff records and records relating to other aspects of the home are well kept, regularly reviewed and up-dated and held securely to protect resident confidentiality. The last inspection reported that the home’s system for reviewing quality in the home involved resident care reviews. Since the last inspection regular reviews of residents care are now undertaken, Ms Dacey wanted to involve the resident’s families in these reviews. Whilst this is a good method of ensuring resident and family involvement in their care packages, it is not what is required under regulation 24 (standard 330 with regard to quality assurance and review. It is expected that the registered providers will establish a system of reviewing and auditing all areas of practice and services, seek the views of residents and their carers and produce as a result, a development plan that will provide measurable criteria on which to base future improvements. This area was discussed again during this visit and Mrs Hughes agreed to look into methods of effective review and audit. Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 X X 3 3 x Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 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. Standard Regulation Requirement The registered person must be able to demonstrate that training provided for staff during induction is assessed to a level to indicate their competence with the taught units. Foundation training must be provided within the prescribed time-scales for new staff. This requirement has been partially met since the last inspection The registered manager must have a written job description clearly defining her duties, responsibilities and accountability. The registered manager must have sufficient time to carry out necessary administrative and management duties. Previous time-scale of 01.09.05 not met. The registered provider must inspect the home, at least once each month and interview, with their consent and in private, such of the service users, their representatives and persons working at the care home as is necessary to form an opinion of
DS0000026795.V255708.R01.S.doc Timescale for action 1 OP30 18 31/01/06 2 OP31 9 31/12/05 3 OP32 26 31/12/05 Autumn Care Version 5.0 Page 25 4 33 24 the standard of care provided. The inspection must also include an inspection of the premises, its records of events and any complaints. A report of the visit must be made available to the Commission and to the registered manager. Previous time-scale of 01.09.05 not met. The registered person must establish a system for reviewing and improving the quality of care in the home and to supply residents (and the commission) with a copy of the report of the review carried out, the system for review must provide for consultation with residents and their carers. Previous timescale of 01.09.05 not met. 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Whilst it is acknowledged that resident’s social histories are being obtained, it is recommended that Autumn Care provide social care that meets the needs of residents individually and in groups in accordance with their wishes and preferences for social, recreational and cultural activity. The registered person should demonstrate that an assessment of the premises has been undertaken by a suitably qualified person in order to establish the extent of the disability equipment and any aids and adaptations required to meet eth needs of service users. It is recommended that the staff duty rota identify the roles of the people on duty. 1 OP12 2 OP22 3 OP27 Autumn Care DS0000026795.V255708.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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