CARE HOME ADULTS 18-65
Baronsmede Queens Road Crowborough East Sussex TN6 1EJ Lead Inspector
Elaine Green Unannounced Inspection 24th July 2006 13.30 Baronsmede DS0000021039.V291694.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 Baronsmede DS0000021039.V291694.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. Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Baronsmede Address Queens Road Crowborough East Sussex TN6 1EJ 01892 654057 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) Baronsmede Family Homes Ltd Mrs Norma Martin Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. The maximum number of residents to be accommodated is nine (9). Only service users with a learning disability may be accommodated. Service users should be aged between eighteen (18) and fifty-five (55) years on admission. Service users with additional physical disabilities requiring the use of a wheelchair should not be accommodated. 6th March 2006 Date of last inspection Brief Description of the Service: Baronsmede is a large detached house in a residential part of Crowborough near to the shops and other amenities. The house provides care for up to 9 adults with a learning disability. Seven of the nine rooms have en-suite facilities. Communal facilities include a lounge, dining room lounge and a conservatory. There is a large garden with a patio to the rear of the house. Baronsmede is one of three homes owned by Baronsmede Family Homes Limited. Day care services are provided at the organisations day centre that is situated nearby. The proprietor has not notified the Commission for Social Care Inspection of the fees charged to service users of the Old Hay Barn. Baronsmede DS0000021039.V291694.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 on the 25th July 2006 between 13.30 and 21.30 and was carried out by two Inspectors. Prior to the Inspection the registered manager was sent a Pre Inspection Questionnaire to provide the Inspector with statistical information about the running of the home and some service user surveys to hand out to the service users, their relatives and other visitors were given the opportunity to complete comment cards to reflect their views on the services provided by the home. Unfortunately these were not returned to the Inspector so feedback from them will not be included within the report. As part of the Inspection the Inspector had a tour of the home, had discussions with the registered manager and staff re the day-to-day running of the home, discussions with service users re their experience of living in the home, and with the proprietor re the overall management of the home. A range of the homes policies and procedures, daily records and other documentation were also examined. What the service does well: What has improved since the last inspection?
Some improvements have been made in respect of care planning. The home has adopted a new system for recording the care plans and they are now more reflective of the lifestyles and care needs of the individual. Service users’ preferences in respect of the way they receive their care and their likes and dislikes are now documented. Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 6 Improvements have been made to the environment and the kitchen cupboards, worktops and cooker have been replaced. One of the service users is moving to a bedroom that will better suit her needs and she stated that she will be choosing the colour of the walls and bedding herself. The home was generally cleaner than at the last Inspection. In relation to management issues, although a shift leader is not indicated on the rota the manager explained that the most senior person on duty delegates the tasks for the day and nominate an individual to administer the medication. Policies and procedures have been reviewed and amended in relation to supporting service users in finding appropriate advocates, medication administration, complaints and adult protection. Management monitor the staff team’s understanding of the homes’ policies and procedures whether or not they are implementing them. One of the ways they do this is through supervision. A new training programme has been implemented and all staff will receive training in adult protection. The recruitment and selection of volunteers now includes obtaining the relevant identity and security checks. What they could do better:
Gaps in the care planning were identified and requirements made in relation to care plans becoming more individualised. Not all care plans contain the guidance that staff require in order to support service users in all aspects of their daily lives including participating in the running of the home or in the management of challenging or difficult behaviours. Care plans must clearly link in with the daily record keeping and review and assessment processes. It should be possible to track through the use of records when service users have made decisions about their lives and this should link to the goals they set themselves at reviews. Progress made should be monitored on a continuous basis and it should be possible to illustrate progression through these records. 50 of the staff team employed by the home must obtain a relevant National Vocational Qualification (NVQ) at Level 2 or above and the manager must obtain the relevant management qualifications. Only one staff meeting had taken place since the last Inspection in March of this year. It had been required that they take place a minimum of 6 times a year. Several shortfalls in relation to protecting service users health and safety were identified at the site visit. Hot water from some of the hot water outlets accessible to service users was extremely high posing a potential risk of scalding to service users an immediate requirement was made for hot water to be regulated at the recommended temperature. An immediate requirement was also made for the practice of wedging fire doors open to stop. It was required at the last Inspection that window restrictors were fitted to all windows subject to a risk assessment. This requirement has not been met. Care plans do not contain all the environmental risk assessments that are required. Not all areas of the home were clean and hygienic. Guidance must be sought from relevant health care professionals in relation to when ‘as and when’ medication can be administered.
Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 7 The proprietor must ensure that monthly, unannounced visits are undertaken and that the manager and the CSCI are sent a report. This requirement is also outstanding from the last Inspection 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. Baronsmede DS0000021039.V291694.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 Baronsmede DS0000021039.V291694.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): 1,2,3,4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can test-drive the home and would be supplied with the information required in order to make an informed decision about whether to reside in the home. EVIDENCE: There have been no new admissions to the home since the last Inspection. Both the manager and provider were able to explain the procedures in relation to assessing a prospective service user and stated that any prospective service user would be invited to come and look round the home, meet the other residents and staff, come for a meal and be able to test drive the home before making a decision about whether to reside there permanently. The manager stated that she would confirm in writing whether or not the home could meet the prospective service users’ assessed needs and that all the relevant information and documentation including a copy of the statement of terms and conditions would be made available to the prospective service user prior to admission. Baronsmede DS0000021039.V291694.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): 6,7,8,9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Gaps were identified in the care planning system currently used and service users involvement in the running of the home is not documented. EVIDENCE: Since the last Inspection the home has introduced a new care-planning tool. Only some service users have their care plan transferred onto the new format however in the ones that have been completed there have been improvements made in relation to the amount, quality and detail of the information that the care plans now contain and they now reflect residents’ daily lives more accurately. All care plans now contain a weekly timetable illustrating the activities participated in and include the preferred activities for evenings and weekends. Through talking to staff and observations on the site visit it appears that service users needs are being met and that staff have a good insight and understanding of the service users needs including the management of difficult or challenging behaviours. The examination of some of the care plans showed that the detail required in order to support service users with their behaviours was not always contained in the care plan in sufficient detail. For example, one care plan documentation referred to a need to minimise this service user’s
Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 11 level of anxiety and encourage attendance at day services but no clear guidelines were available to guide staff as to how to achieve these. Although a member of staff was able to describe how they would support this person to minimise incidents of challenging behaviour, there were no guidelines available to ensure a consistent approach can be taken by staff. Service users’ personal goals are not specified in their care plan and progress made towards meeting these goals is not documented. Overall care plans need to become more individualised and service users daily records, reviews and care plans should clearly link up so it is possible to track from daily records how and when serviced users and staff have met to discuss their aims and objectives and the progress made towards meeting goals set at previous reviews should be monitored. Currently service users goals are recorded at reviews but there is no evidence or audit trail of the assessment process, meetings, and discussions with service users that have lead to these decisions being made. Goals set at reviews should be documented in the care plan. Service users and staff stated that service users assist in the running of the home e.g. laying the table and loading the dishwasher etc. however the level of participation is not documented in the care plan. Service users should be encouraged as far as possible to participate in all aspects of running the home, subject to risk assessments, including joining staff meetings, representation in management structures etc. Though improvements have also been made in respect of documenting the risk assessments undertaken for each resident, further risk assessments are required. These must specify whether or not individuals can safely access areas of the home and grounds unsupervised and if not what measures are taken to ensure residents safety e.g. doors locked or staff support required. A number of risk assessments had recently been reviewed, in July 2006. Gaps in daily record keeping were identified and the manager explained that this was to be discussed at the next staff meeting and training provided for those staff who required it. Baronsmede DS0000021039.V291694.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): 12,13,14,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents with the opportunity to access the community and participate in meaningful and appropriate activities. Residents are provided with a healthy diet. EVIDENCE: Through discussions with residents and staff and the examination of daily records it is evident that many residents lead active lifestyles. The day care facility at the site of one of the other Baronsmede Family Homes is open every day and some evenings when it can be accessed for recreational and leisure activities such as table tennis and pool. Trips out are organised at the weekends and some evenings. A group supported annual holiday is provided for those who want to go. Some residents are able to assist in the running of the home and participate in activities such as doing their own laundry, laying the table, food preparation etc. Residents spoke positively of the home. For example, one resident stated “staff are brilliant” and another said “living here is lovely”.
Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 13 Care plans specify family relationships and peer group relationships pertinent to the individual. Residents and staff stated that residents’ visitors are welcomed into the home and that some of the residents visit their families on a regular basis. Records confirmed this. One Inspector joined residents for evening meal. The food served was nutritious and a choice was available. The atmosphere during mealtime appeared relaxed and staff interacted with residents appropriately, offering support when required. An examination of menus confirmed that the home provides the service users with a wholesome varied and nutritious diet. Baronsmede DS0000021039.V291694.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): 18,19,20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ health care needs are met and personal support is provided appropriately. The homes’ medication policies and procedures are safe. EVIDENCE: Some care plans include instruction and guidance for staff to follow in relation to residents’ preferences for how they receive personal care. It is required that all care plans specify whether or not a resident has preferences and the new care planning system allows for this. Observation of practice on the day of the site visit, an examination of records and discussions with residents and staff confirms that residents’ health care needs are met. Referrals are made for input from health care professionals when required and residents receive support and treatment in the privacy of their own rooms. Medication records were examined and found to be in order. Staff were observed administering medication during the site visit and followed the homes policies and procedures which are safe. Guidelines for the administration medication of ‘as and when’ medication must be obtained from relevant health care professionals and be available to all staff responsible for it’s
Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 15 administration. The manager explained that she was aware of the need for this to happen and that this was in hand. Baronsmede DS0000021039.V291694.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): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints policy and procedures have been reviewed and amended. The homes’ adult protection policies and procedures protect residents from abuse and harm. EVIDENCE: The home has reviewed and amended their complaints policies and procedures and they are now a lot clearer. Service users stated that they felt confident in approaching the manager and or staff if they had a problem. Some residents can display a level of behaviour that may be challenging. The manager and provider have both received training in relation to the protection of vulnerable adults and a programme for all staff to receive this training is in place. Referrals are made to the local social service department when an adult protection alert is required in line with local guidance. Staff have a good understanding of adult protection issues and of how to make an adult protection alert. Baronsmede DS0000021039.V291694.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): 24,25,26,28,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable and service users own rooms promote their independence. EVIDENCE: Four residents showed the Inspectors their bedrooms. All these rooms were personalised and located in the area of the house best suited to the individuals’ needs thus maximising their safety and independence. Residents have their own belongings in their rooms and can choose their own décor and furniture. One resident explained how she due to move rooms and was going to choose the colour of her room and curtains herself. The home has a large television lounge, smaller lounge by the kitchen and a conservatory, which is used for dining. One service user has a lounge area on the first floor. The kitchen cupboard doors and worktops have been replaced and a new cooker has been installed. These rooms are all homely in character. The manager and proprietor explained that improvements had not been made in the past to the environment at Baronsmede due to the uncertainty of the homes long term future and the possibility that the home may relocate to a purpose built building on the site of the Old Hay Barn one of Baronsmede sister
Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 18 homes. These plans have now been put on hold so further improvements are planned to upgrade and redecorate the home. The areas of the home inspected on the day were mainly found to be clean tidy and hygienic however, some of the carpets required vacuuming and one of the service users bathrooms required cleaning. Residents and their key workers are responsible for keeping bedrooms clean and tidy. Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment procedures are good and consistently followed. All staff receive regular documented supervision and appropriate training. Albeit thee staff employed by the home are experienced the level of qualified staff is below those recommended. EVIDENCE: Each home within the group of Baronsmede family Homes has a designated staff rota and although staff may be called on to work in other homes to cover on occasions, on the whole they work at the same home on a regular basis. This provides continuity in the care and support provided to residents of the home. Records relating to staff training, induction and supervision were examined confirming that appropriate training is provided for all staff and that supervision takes place on a regular basis. One member of staff’s file stated that the person had attended a range of training both prior to joining Baronsmede and since, but there was little evidence of prior training. It is suggested that this is followed up with all members of staff. Each member of staff receives an annual appraisal from the deputy manager where training needs are identified and a training and development plan is implemented. Staff spoken with confirmed that they had attended a range of training including food hygiene and nutrition, medication and updated adult protection training.
Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 20 Two recruitment files were examined and were found to contain all the relevant information and confirmation that all the require checks had been undertaken satisfactorily prior to them being deployed to work in the home. The home continues to work towards 50 of the care staff employed obtaining a National Vocational Qualification (NVQ) Level 2 or above in Care. The manager assured the Inspectors that the current staffing levels could meet the needs of the residents. Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is experienced however, service users health and safety is not always protected and promoted. EVIDENCE: The manager of the home has the relevant experience and although she is working towards achieving her Registered Managers Award she does not currently hold the relevant qualifications. A requirement was made at the last Inspection for the provider to undertake monthly, unannounced visits to all their homes and provide a written report to the manager and to the Commission for Social Care Inspection (CSCI). To date no unannounced visits have been made. The Baronsmede family Homes organisation has it’s own service improvement questionnaire that is sent to relatives of the service users resident in their homes. Residents meetings are also held in order to gain service users views on the running of the home. It is recommended that the home explores other ways of ensuring they are running
Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 22 the home in the best interests of the service users and introduces a system of self audit and quality monitoring. A requirement was made at the last Inspection for window restrictors to be fitted to all windows subject to a risk assessment. This requirement has not been met. The temperature of the water from several of the hot water outlets accessible to service users was found to be excessively hot and could pose a risk to service users. For example, the water from the ground floor bathroom was recorded as 60οC for the bath outlet. Although the home was aware of this and were managing this by removing the hot tap, this was not the case on the day of the inspection and this needs to be resolved urgently. The hot water must be regulated at the recommended temperature and be monitored and recorded on a monthly basis and an immediate requirement to this affect was made. Door wedges were widely used throughout the home on fire doors this practice must stop and an immediate requirement was made. The accident and incident logs were inspected and were being maintained appropriately. Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 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 3 25 3 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 3 X 2 X X 1 x Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 24 YES Are there any outstanding requirements from the last inspection? 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 13(4) 14 15(1) Sch 3(1a) Timescale for action Care plans must be based on a 30/09/06 robust assessment process and include all areas as specified in standards 2, 6, 7 & 16. Service users involvement must be documented. Timescale 30/05/06 not fully met. The home must be able to 30/10/06 demonstrate how and when decisions are made by service users or others on their behave in relation to life choices and goal setting. Service users must have 30/10/06 opportunities to participate in all aspects of the running of the home and supported to do so subject to risk assessments. The level of participation must be documented in the care plan and kept under review. Risk assessments must be 30/08/06 undertaken to specify whether or not individuals can safely access areas of the home and grounds unsupervised and if not what measures are taken to ensure residents safety e.g. doors locked or staff support required. All service users must be 30/09/06
DS0000021039.V291694.R01.S.doc Version 5.1 Page 25 Requirement 2. YA7 12(3) 3. YA8 24(3) 4. YA9 13(4b) 5. YA18 12(1a) Baronsmede (2) (3)(4ab) 6. YA20 13(1b2) 7. 8. YA30 YA32 13(3) 18(1) 9. YA33 12(1ab) 18(1) 26 10. YA39 11. YA42 12(1a) 13(4,5) 12. YA42 12(1a) 23(2p) 13. YA42 12(1a) 13(3,4,6) consulted with in relation to their preferences for the way in which support and personal care is provided. Timescale 30/05/06 not met. Guidelines in relation to when ‘as and when’ medication can be administered must be gained from the relevant health care professionals. That all areas of the home are kept clean and hygienic. 50 of the staff team employed have a relevant NVQ at Level 2 or above. Timescale 30/09/06 not yet reached. Staff meetings must take place regularly and at least 6 times a year. Timescale 30/06/06 not met. The provider must ensure that monthly, unannounced visits are undertaken and that the manager and the CSCI are sent a report. Timescale 30/04/06 not met. With immediate affect fire doors must not be wedged open. Immediate requirement left at the home. Confirmation of the action taken must be confirmed in writing. Within 24 hours hot water temperatures must be regulated at the recommended temperature, be monitored and recorded on a monthly basis. Immediate requirement left with the home. Confirmation of the action taken must be confirmed in writing. Window restrictors must be fitted to all windows subject to a risk assessment. Timescale 30/03/06 not met. 30/09/06 30/09/06 30/09/06 30/09/06 30/09/06 24/07/06 24/07/06 30/10/06 Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA39 Good Practice Recommendations That the home explores other ways of ensuring they are running the home in the best interests of the service users and introduces a system of self audit and quality monitoring. Baronsmede DS0000021039.V291694.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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