CARE HOME ADULTS 18-65
Baronsmede Queens Road Crowborough East Sussex TN6 1EJ Lead Inspector
Elaine Green Announced Inspection 6th March 2006 09:00 Baronsmede DS0000021039.V275373.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.V275373.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.V275373.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.V275373.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. 27th June 2005 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. Baronsmede DS0000021039.V275373.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 6th March 2006 between 09.00 am and 4.30 pm. Prior to the Inspection the registered manager completed a Pre Inspection Questionnaire to provide the Inspector with statistical information about the running of the home and 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. 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, discussions with three service users parents as to their views of the services provided 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. As not all the National Minimum Standards were examined as part of this Inspection this report should be read in conjunction with the previous report. What the service does well: What has improved since the last inspection? What they could do better:
Gaps were identified in the care plans examined. Clear guidance must be
Baronsmede DS0000021039.V275373.R01.S.doc Version 5.1 Page 6 provided for staff to follow including the recording and reporting of incidents where appropriate. Service users involvement in writing their care plans is not documented and all service users should be consulted with in relation to their preferences for the way in which support and personal care is provided. The manager assured the Inspector that a new care planning system about to be introduced by the home would cover all the gaps identified with their current system. It is required that the home reviews their policies and procedures in relation to supporting service users to find appropriate independent advocates and that these policies are consistently followed. Requirements are made for consultation to take place with service users in relation to what weekend activities individuals prefer to participate in. Medication administration policies and procedures must be reviewed and the lines of accountability for administration must be clearly identified. Specific guidance required for staff to follow in relation to administering medication to service users must be readily accessible to staff at all times. Management must also review and amend their policies and procedures in relation to complaints and Adult Protection to ensure that they are in line with National Minimum Standards and local guidance. Several issues were identified in relation to the effective staffing of the home. Evidence suggests that the staff rota is not always based on an assessment of service users needs, there is not always a senior member on duty and a shift leader is not identified on the rota. Other staff issues include that fact that staff meetings do not take place regularly and that identity and security checks have not been completed for volunteers. Management must ensure that supervision of staff is effective and used appropriately and that training undertaken by staff is effective with particular reference to issues of adult protection and medication highlighted within the report. Copies of certificates must be kept on personnel files. Tensions and divisions within the staff team need to be addressed and strategies for enabling staff to voice concerns effectively must be put in place. 50 of the staff team employed by the home must obtain a relevant National Vocational Qualification (NVQ) at Level 2 or above. The home must be ‘deep cleaned’ and all windows must be fitted with window restrictors subject to a risk assessment. Substances hazardous to health must be stored appropriately. The proprietor must ensure that monthly, unannounced visits are undertaken and that the manager and the CSCI are sent a report. The management must ensure that all the homes policies and procedures are implemented and that they are signed and dated by the registered manager. All records required by regulation must be maintained, up to date and accurate. Baronsmede DS0000021039.V275373.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Baronsmede DS0000021039.V275373.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.V275373.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): These standards were not Inspected EVIDENCE: Baronsmede DS0000021039.V275373.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. Gaps were identified in the care planning system currently used. The right for service users to make decisions is not assessed or documented. EVIDENCE: Three care plans were examined. The quality of the information contained in the care plans varied and gaps were identified. None of the plans were complete for example, one care plan did not contain a property list, the general information section had not been completed and there was no information relating to medication. In addition to this the guidance for staff to follow in relation to supporting individuals with their specific care needs and management of challenging behaviours were missing in some cases. The risk assessments contained in the care plans examined had not been reviewed regularly and the right for service users to make decisions is not assessed or documented. Not all documentation and records were signed and dated. Requirements are made for care plans to be based on a robust assessment process and cover all areas specified in Standards 2, 6 & 7. Service users involvement must be documented. The manager assured the Inspector that the home is in the process of introducing a robust new care planning system which will cover the gaps identified.
Baronsmede DS0000021039.V275373.R01.S.doc Version 5.1 Page 11 Though two care plans specify that service users have advocates, there were no records of the involvement of either the advocates or service users in the assessment process or the writing of care plans. Service users advocates are not always independent of the home. It is required that the home reviews their policies and procedures in relation to supporting service users to find appropriate independent advocates and that these policies are consistently followed. The reasons for any exceptions must be clearly stated. Baronsmede DS0000021039.V275373.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. Albeit service users have the opportunity to participate in meaningful, stimulating and appropriate activities during the week, there is little evidence of weekend activities being offered or provided. Daily routines promote independence though are not adequately recorded. Service users are part of the local community and maintain family relationships. EVIDENCE: Service users are encouraged and supported to attend a range of varied and appropriate courses at the homes’ own day care centre as well as those run by other local colleges. Service users are fully involved with the planning of trips and activities at the day care facility and update their own web site so that friends and families can see what they have been doing. Service users have their own e-mail addresses and are encouraged to communicate with their family and friends over the Internet. Some service users participate in courses run to support them with their daily living skills and personal safety at Baronsmede. Further developments heave been made in respect of a diarised “Week in the Life” for individual service users which is being documented on the computer at the day care facility. This facility continues to provide
Baronsmede DS0000021039.V275373.R01.S.doc Version 5.1 Page 13 stimulating, meaningful and relevant activities for service users to participate in and staff appear open and enthusiastic about the work they do there. Service users stated that their friends and family visit them in the home and that they go and visit them. They also spoke about going to the local shops and pubs. The service users and three visiting relatives gave very positive feedback to the Inspector re the social aspects of living at the Baronsmede. They stated that they have regular contact with the manager of the home and that there is always lots of things going on. They spoke of the life at the home being that of a normal family life and that service users speak of ‘going to work’ when they go out in a morning. However, a lack of appropriate activities provided at the weekend was identified, particularly in relation to those less able. An examination of records and care plans confirmed this. Requirements are made for consultation to take place with service users in relation to what weekend activities individuals prefer to participate in. One service user visits a staff members’ home, these visits must be risk assessed and fully documented as they would be for any other respite visit or holiday. Through discussions with service users, their relatives and staff it was evident that service users participate in the running of the home on a daily basis and that they each have responsibilities in relation to this. The examination of care plans and records does not reflect this. Baronsmede DS0000021039.V275373.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): 18,20. It is unclear whether service users receive the personal support in the way that they prefer and require. Guidelines, policies and procedures in relation to the administration of medication are not consistently followed. EVIDENCE: Care plans were examined and they do not reflect service users wishes in respect of specifying the way in which they prefer their personal support to be delivered. An example of this is that the manager and staff stated that one service user prefers to be given personal support by a female and this was not documented in her care plan. It is required that all service users are consulted with in relation to their preferences for the way in which support and personal care is provided and that this is specified on their care plan. On the day of the Inspection medication records were examined and discussions took place with management and staff in relation to the administration of medication procedures, particularly with regard to those administered outside of the home. The box in which medication is transported was examined and found to contain medication that was out of date and should have been disposed of. When staff were asked where they would record medication that had not been given and how they would pass this information on to the next shift they were unsure and did not know who was responsible for ensuring this happens. It was also stated that at times they have been
Baronsmede DS0000021039.V275373.R01.S.doc Version 5.1 Page 15 required to administer medication without a medication-recording sheet. Staff were unaware of the procedure to follow in relation to the recording of ‘as required’ (PRN) medication and of how this information is passed on to other staff. It was also noted that some of the PRN medication and the guidance for when it is to be administered is kept at the home and not carried with staff. Requirements are made for the management to review all their medication administration policies and procedures and to ensure that the members of staff responsible for administration of medication are confident and competent in following them. The lines of accountability for ensuring these policies and procedures are followed at each shift must be clearly identified and it is recommended that the management ensure that this is specified on the staff rota. Baronsmede DS0000021039.V275373.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. The homes’ policies and procedures in relation to complaints are inadequate and complaints made have been poorly managed. The homes’ policies and procedures in relation to the protection of vulnerable adults are inadequate and have the potential to place service users at risk. EVIDENCE: Within the last 12 months, concerns of a serious nature regarding the safety of service users in their care were raised with the management of Baronsmede Family homes. These concerns were managed poorly and inappropriate investigations undertaken by the management and staff had the potential to further compromise service users safety. The home failed to refer incidents that should have resulted in an Adult Protection Alert being raised to the appropriate social services team, report them to the Commission for Social Care Inspection (CSCI) or to fully inform the service users family and care managers. The homes’ policies and procedures in relation to the protection of vulnerable adults were examined and found to be inadequate. They are not in line with the local guidance specified in the Brighton & Hove East Sussex, Multi Agency Guidelines for the Protection of vulnerable Adults. A requirement is made for these to reviewed and amended as required and to ensure that they clearly specify who staff should refer an incident of suspected abuse to i.e. the local social services Community Learning Disability Team, that the CSCI is informed and that the service users relatives and care manager is kept informed and up to date with what is happening. Management must ensure that all staff are familiar with these guidelines and are competent and confident in following the relevant procedures should they suspect an incident of abuse has occurred.
Baronsmede DS0000021039.V275373.R01.S.doc Version 5.1 Page 17 Guidance should be included in care plans for staff to follow in relation to implementing these policies where appropriate. Baronsmede DS0000021039.V275373.R01.S.doc Version 5.1 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,28,30. The home is comfortable and safe but in need of a deep clean. Service users own rooms are personalised and promote their independence. EVIDENCE: The Inspectors had a tour of the building and had discussions with the registered manager and the proprietor in relation to the homes’ environment. The home is domestic in character and homely. Some areas of the home are in need of decorating and updating. The management have already identified a number of minor repairs and redecoration that need attention in the home and assured the Inspectors these were in hand. Of concern was the general level of cleanliness throughout the home and a requirement is made for deep cleaning to take place, this was discussed at the Inspection and the manager was in agreement. Service users bedrooms are personalised with their own belongings and furniture. Two service users have their own separate lounge area where they can make themselves hot drinks and socialise away from he rest of the group. The ground floor provides two lounge areas and a conservatory so there is ample space. Baronsmede DS0000021039.V275373.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): 31,32,33,34,35,36. The lines of accountability and staff roles and responsibilities are unclear. Some staff training and supervision is ineffective. Service users individual and group needs are not consistently met. Recruitment procedures in relation to volunteers are inadequate. EVIDENCE: Recent Adult Protection issues within the home and discussions with management and staff have highlighted that the roles and responsibilities of staff within the Baronsmede Family homes are not clear. Staff do not consistently follow the homes own policies and procedures and although they are given a full set of policies and procedures neither their understanding of them or compliance with them is monitored effectively. An examination of the staff rota shows that at times there are junior members of staff on duty at the same time and no senior. No shift leader is indicated on the rota it is therefore impossible to identify who would manage any emergency or organise the administration of medication etc. Discussions with staff indicated that they write and or change the rota’s themselves rather than it being based on service users assessed needs and who can best support them. Requirements are made to address these issues. Though many of the staff team are working towards achieving National Vocational Qualifications (NVQ) in Care, records indicate that less than 50 of
Baronsmede DS0000021039.V275373.R01.S.doc Version 5.1 Page 20 the staff team hold a relevant NVQ at level 2 or above. Requirements are made. Discussions with staff in relation to issues of medication and the Protection of Vulnerable Adults confirmed that the training they had received had been ineffective. The training provided by the home for the majority of the staff in relation to Adult Protection issues was in the form of videos. One staff member had watched videos for the last 5 years without receiving any other specific training and was not aware of the local guidance the home is required to work to. There was no evidence of an effective and relevant training plan in place for staff. Requirements are made in respect of the effectiveness of training. Some of the service users attend a social club on the site of one of the other homes’ in the group on a Friday evening. Volunteers and staff from Baronsmede support this club. The home had not obtained the relevant identity and security checks for these volunteers. Requirements are made. Records in relation to staff meetings and supervision were examined. Records show that staff meetings do not take place on a regular basis. Although records show that supervision does take place on a regular basis staff state it is not effective and that the management does not use supervision to address issues appropriately. Requirements are made in relation to staff meetings and supervision. Baronsmede DS0000021039.V275373.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): 37,38,39,40,41,42. Service users rights, health and safety and best interests are not consistently protected. There are shortfalls in record keeping and some of the homes policies and procedures. There is no provision for quality monitoring. EVIDENCE: The mismanagement of complaints and adult protection issues coupled the lack of effective training and supervision of staff has had a negative impact on the provision of care and support to some service users in the home. The management have failed to ensure that staff are confident in raising concerns to them and that their concerns will be taken seriously. There are divisions and tensions within the staff team and this need to be addressed. Management do not have an effective quality assurance monitoring system in place. There is no system in place to identify when staff are not carrying out their duties as is required by their own policies and procedures. The organisation as a whole has not been working in a multidisciplinary way as local guidance specifies. Baronsmede DS0000021039.V275373.R01.S.doc Version 5.1 Page 22 The National Care Standards specify that the provider must 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). This does not happen. As already specified in the report some of the homes policies and procedures are required to be reviewed and amended. All policies and procedures must be signed and dated by the registered manager. Many of the records examined were not signed and dated and incidents have been poorly and inadequately recorded. There is a need for improvements to be made in relation to recording of information throughout the organisation as a whole and requirements are made. These issues have been discussed with the management of the home. The home must ensure that all substances hazardous to health are kept locked away. This includes service users toiletries and kitchen cleaning products such as washing up liquid. Service users may keep their own toiletries in their rooms subject to risk assessments. Windows restrictors must be fitted to all rooms subject to a risk assessment. Baronsmede DS0000021039.V275373.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 X 2 X 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 1 23 1 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 X 30 2 STAFFING Standard No Score 31 2 32 2 33 2 34 2 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 2 2 1 2 2 2 2 Baronsmede DS0000021039.V275373.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 13(4) 14 15(1) Sch 3(1a) 20(3) Timescale for action Care plans must be based on a 30/05/06 robust assessment process and include all areas as specified in standards 2, 6, 7 & 16. Service users involvement must be documented. It is required that the home 30/04/06 reviews their policies and procedures in relation to supporting service users to find appropriate independent advocates and that these policies are consistently followed. Requirements are made for 30/05/06 consultation to take place with service users in relation to what weekend activities individuals prefer to participate in. All service users must be 30/05/06 consulted with in relation to their preferences for the way in which support and personal care is provided. Medication administration 10/04/06 policies and procedures must be reviewed and amended. Management must review and 10/04/06 amend the policies and procedures in relation to complaints.
DS0000021039.V275373.R01.S.doc Version 5.1 Page 25 Requirement 2. YA7 3. YA14 16(m,n) 4. YA18 12(1a) (2) (3)(4ab) 13(2) 21(1,2) 22(1,2,3, 4,5,6,7,8) 5. 6. YA20 YA22 Baronsmede 7. YA23 12(1,5) 13(4,6) 17(1) 37 8. 9. 10. 11. YA30 YA31 YA32 YA33 12(1) 23(1) 18(1) 18(1) 18(1) 12. 13. YA33 YA34 12(1ab) 12(1a) 14. YA35 18(c) 18(2) Sch 4 15. 16. 17. YA36 YA37 YA38 18(2) 12(1a) 18(1,2,4) 24,26 12(5a,b) 21(1,2) Management must review and amend their policies and procedures in relation to Adult Protection to ensure that it is in line with local guidance. Clear guidance in relation to implementing these policies should be included in service users specific guidelines were appropriate. The home must be ‘deep cleaned’. A shift leader is identified on the rota at each shift. 50 of the staff team employed have a relevant NVQ at Level 2 or above. The staff rota must be based on an assessment of service users needs and a senior member of staff must be on duty at all times. Staff meetings must take place regularly and at least 6 times a year. Recruitment and selection of volunteers is robust and all the relevant security and identity checks must be completed before they may work with service users. Management must ensure that training undertaken by staff is effective with particular reference to issues of adult protection and medication highlighted within the report. Copies of certificates must be kept on personnel files. Management must ensure that supervision is effective. The management must ensure that the homes policies and procedures are implemented. The manager must ensure that there are strategies for enabling staff to voice concerns effectively and that the process of
DS0000021039.V275373.R01.S.doc 10/04/06 30/04/06 10/04/06 30/09/06 10/04/06 30/06/06 10/04/06 30/09/06 30/05/06 30/04/06 30/05/06 Baronsmede Version 5.1 Page 26 18. YA39 26 19. YA40 20. YA41 4(1,2,3) 5 6 12(1a) 13 17(2,3,4) Sch 1,2,3,4 12(1a) 13(3,4,6) management of the home is open and transparent. The provider must ensure that 30/04/06 monthly, unannounced visits are undertaken and that the manager and the CSCI are sent a report. The homes written policies and 30/05/06 procedures must be signed and dated by the registered manager. The management of the home 30/04/06 must ensure that all records required by regulation are maintained, up to date and accurate. All windows must be fitted with 30/03/06 window restrictors subject to a risk assessment. All substances hazardous to health must be stored appropriately. 21. YA42 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 YA20 Good Practice Recommendations The lines of accountability for ensuring medication administration policies and procedures are followed at each shift must be clearly identified and it is recommended that the management ensure that this is specified on the staff rota. Baronsmede DS0000021039.V275373.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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