Inspection on 06/06/05 for Birch House

This inspection was carried out on 6th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Birch House 31/12/08

Birch House 03/01/07

Birch House 26/09/05

Birch House 26/11/04

Birch House 02/08/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Birch House The Street Appledore Kent TN26 2AF Lead Inspector Lois Tozer Announced 6 June 05 09:30 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 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 Stationary 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. Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Birch House Address The Street Appledore Kent TN26 2AF 01233 758527 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Nexus Direct Limited Ms Sharon Anne Gedling CRH 3 Category(ies) of Care Home - Learning Disabilities. registration, with number of places Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration conditional on Manager completing NVQ4 in management. Date of last inspection 26th November 2004 Brief Description of the Service: Birch House is a large, detached property situated in the village of Appledore, on the edge of Romney Marsh. It is owned by the company Nexus Direct and is managed on a day-to-day basis by registered manager, Ms Sharon Gedling. Set in its own spacious grounds, access to local facilities such as the village shop and post office, pub and recreation ground are minutes walk away. There is a train station situated a brisk 20 minutes walk from the home and an infrequent public bus service is available. The home has access to a dedicated vehicle and is able to have access to a second company vehicle if required. The home offers accommodation to a maximum of 3 people who have learning disabilities and fall between the age ranges of 18 to 65. The house offers a large communal lounge / diner, kitchen, laundry, WC and spacious lobby on the ground floor. All bedrooms and the office are situated on the first floor, with easy access to an additional WC and large bathroom. The garden is managed by the residents with staff support, and the development of a conservation area at the back encourages wildlife to use this habitat. A spacious gravelled area allows residents to air-dry clothes without getting muddy. The large front garden is currently being landscaped. Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory announced inspection took place on 6th June 2005 between 9.30am and 5.00pm and 10th June 2005 between 4.00pm and 5.30pm. There are currently two people living at the home, both residents were happy to give lots of feedback to help with the inspection process. The second resident has a busy life outside of the home, so the return date of 10/6/05 was made to catch up with them to seek their views. Paperwork seen included individual goal and support plans, risk assessments and records of support and participation in activities; medication and administration documents; policies and procedures; assessment documents; staff recruitment details and files; training details, quality assurance, duty rota and health and safety documentation. The house is a pleasant, well-presented abode. Landscaping work to the front garden commenced the first day of this inspection. Work will be carried out during the summer 2005 to replace all the windows and patio door to the rear of the premises. There is a high level of activities available to both residents and the range of choice for activities outside of the home is extensive and well supported both financially and by staff availability. Comments expressing the suitability of the home’s services were made clear by a resident as follows; ‘I can choose my own things to do, its nice and quiet here and I like it like that. My friends visit and I go to their house. We didn’t get on well when (x) lived here, but now, as a visitor, its fine. I know about my (care) plan, and the rules that help me. I can choose a holiday and this year a group are going, we all get on well. Staff help me read my letters, but I open them. I can spend my money how I like, but staff are helping me save up for furniture and the holiday. There is always someone I can speak to and I feel safe here, staff help to sort out problems. I can get up when I want at the weekend and my favourite things are doing the garden and washing the car. Sharon (the manager) makes sure that everyone has a say in how the house is run, and if its not up to the standards, Sharon will make sure its sorted out.’ Comments that expressed where changes need addressing were as follows ‘Its mostly females here, and I get nagged, its always clean this, clean that. When X visits and I am here, I go to my room coz he winds me up, I don’t like him much. I would like a say in how the house is decorated and who I go on holiday with’. What the service does well: The home promotes an ethic of rights with responsibility, helping residents develop a better awareness of positive behaviours. Residents are supported to develop their life skills with consistent opportunities to practice them and records are kept to be able to monitor individual’s development. Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 6 Access to specialist professionals such as the psychotherapist and psychiatrist to aid such development is facilitated and feedback from meetings has been negotiated with the individual residents permission, helping the staff give continuity of support in line with the professionals suggestions. Opportunities to get out into the community and experience interesting activities such as theatre, bowling, and swimming take place regularly and are enjoyed by residents. Despite being in a rural location, one resident is supported to go to the college of their choice 4 days a week. Residents are fully involved in the running of the home and say that they are consulted about any changes and are helped to plan daily things like menus and events such as holidays. What has improved since the last inspection? What they could do better: There were two areas identified during this inspection that need improvement, they being; the recruitment process of staff and management of medication. Currently, staff are being allowed to work in the home before references have been received and validated and before a POVA (protection of vulnerable adults) check has been carried out. For the safety of the residents, these essential checks must be in place prior to a job being offered. This has formed a requirement and it is essential that the organisation as a whole work with the Department of Health to stamp out the possibility of abusive employees reentering the workplace. Medication management is taken very seriously in the home, but some areas were identified that need improvement to ensure residents safety, these being; staff training by a qualified source – prior to being permitted to administer medication unsupervised. Handwritten directions on medication administration records need to be an exact replica of the label and not use shorthand abbreviations and the medication cabinet must be bolted to the wall. Recommendations stemming from resident feedback are; Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 7 To demonstrate a consultation process has taken place in respect of choice of holiday (especially who they go with) and decoration of the home. Where individuals from other homes visit and there is friction, this must be monitored and action taken to prevent the resident being placed in this position. 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. Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 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 standard(s) 1 & 2 The service user guide is full of valuable information to aid prospective service users to decide if the home is suitable for them, however it is quite complicated and would benefit from simplification, making it more accessible. The assessment process used is in depth and highlights if the home can meet a prospective residents needs and aspirations. EVIDENCE: The manager has produced highly a detailed statement of purpose and service user guide, which have been kept under review. The service user guide is so weighty that it would be difficult for a prospective resident to use without full support; therefore, it is required that over the next 12 months, this document be simplified, where possible with current resident input. A recommended way to present such information is with the use of pictures of the home and statements that summarise the details in the statement of purpose. A holistic needs assessment is used by the home that accounts for all aspects of a prospective residents lifestyle and needs. This tool (HALO) provides the manager with sufficient information to create a working support plan, as required. Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 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 standard(s) 6, 7, 8, 9, 10 Individual needs, aspirations and goals are reflected in the service user plan. The ethos of the home promotes residents to make responsible decisions. Resident consultation takes place for most matters affecting the home, but some shortfalls are perceived by residents. Risks are managed in a way that does not limit individual development. Information and documentation is kept securely and is up to date. EVIDENCE: Ongoing work is taking place on the individual plans to streamline and make them more accessible. Each resident has a care plan that is highly descriptive of individual need and gives practical advice to provide a consistent approach by staff. Restrictions on rights are addressed and consultation with the resident, care management, and other appropriate professionals such a psychoanalyst is recorded. Goals are specific and measurable and are relevant to the resident’s interests and development, such as money skills. A resident made it clear that they are fully consulted in any changes planned and have daily discussions with staff as well as regular house meetings, as a group. This was not supported by the other resident who said they would like a say in how the home is decorated, saying no-one asked regarding the choice of the lounge carpet and who they were going on holiday with. Staff help residents to manage their day-to-day affairs and chores, but the emphasis is on the Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 11 individual residents taking a full and responsible interest in such activities; a resident confirmed that this was welcome and as it should be. Risks both within and outside of the home have been assessed and a management strategy, where required, is in place. Records detailing outcomes relating to risk are in place to assist the management team to accurately review plans and enable residents to develop further. All documentation is kept securely, locked away when not in use. A resident said that they were helped to understand what was in their plan by staff. Care reviews are taking place twice yearly, with invitation to the care manager and other relevant persons. Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 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 standard(s) 11, 12, 13, 14, 15, 16, 17 Practical life skills are encouraged. Activities are chosen by residents and are age, peer, and culturally appropriate, but consultation regarding who residents to go on holiday with needs improvement. Both residents have frequent opportunities to get out into the wider community. Leisure activities are chosen by residents that reflect their own interests. Friendships and family contact is supported by the home. Rights and responsibilities are strongly promoted and generally welcomed by residents. Meals are healthy and mealtimes pleasant. EVIDENCE: Individual development is strongly encouraged through day-to-day participation in household tasks and practical life skills. A resident was proud to say that they had, under supervision, mown the lawn with little assistance. Support to work through difficulties is provided with the additional assistance from qualified therapists, the outcome of any support is recorded to enable the support plans to be reviewed. One resident takes a keen interest in education via a local college; the other had declined this opportunity but is working within the home to develop money and other practical skills. A resident said that they are able to go out to the village or further away to the towns usually Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 13 whenever they fancied. Group activities are organised at the request of residents, usually combining fun days out. A resident said that they really liked to have time to knit and sit quietly without anyone making noise, so this home was ideal. A friend who had lived at the home previously was visiting when the inspector was there, one resident said that it was good to see their friend and they helped each other out with respective gardens, however this was not supported by the second resident (who stated certain personal reasons, confirmed by staff). It is very important that both are equally respected, therefore, such visits should be timed accordingly. Each resident has a schedule of daily tasks that need to be achieved to keep the home clean and tidy. A resident was keen to point out that it is good to know who is doing what and that the rota was fair, saying staff always helped out too, but the other commented that staff could be a bit ‘naggy’. Each resident takes turns to do the cooking and help each other out. Menu’s are prepared by the residents with staff support to help with writing it down. A resident has chosen a healthy eating plan to aid with weight loss and is supported by staff to keep to it. Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 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 standard(s) 18, 19, 20, 21 Personal support is provided in the way individuals prefer & require it. Access to all healthcare professionals is well supported. The staff manage the residents medication, but there are some shortfalls which make the system not as safe as it should be. The policy for ageing, illness, and death meet the needs of this service. EVIDENCE: Neither resident requires a great deal of assistance with personal care, but one resident advised that when this is needed, staff are always kind and are of the same gender. Healthcare is kept under review with access to appropriate professionals supported. Each resident benefits from access to a psychoanalyst and psychiatrist. Medication is monitored and administered by staff, with some very good systems in place, namely a documented audit of medication quantity, booking in and returns system and completed medication administration records (MAR). Shortfalls that compromise the safety of the system were found; Although the home has given ‘in house’ training to staff, several have not received training from a qualified source but are in control of administering medication unsupervised. It is a requirement that suitable training be sought and implemented. New staff should not administer medication until they have received such training and have been deemed competent though the homes own procedures. In line with the TOPSS style induction, staff should receive Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 15 this essential training within 6 months of commencement. Handwritten directions on MAR sheets have been double signed, showing good practice, but the information has not been copied exactly from the direction label provided by the pharmacy and in some cases contains abbreviations and a generic drug name, not that displayed on the label. Exact replication of the label and plain English is required. The medication cabinet is kept within a cupboard, but is not bolted to the wall within, which is required. One minor shortfall was the absence of an ‘as required’ medication protocol, this should be clearly stated within the behaviour management guidelines. Discussion about medication leaving the home safely took place. The policy on sudden death has been reviewed and now makes clear what procedures must be followed. Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 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 standard(s) 22, 23 Residents feel listened to and feel they are safe within the home. There are shortfalls in the protection of service users from the prevention of unsuitable personnel working at the home. EVIDENCE: A resident said that they knew who to speak to if they had a problem and staff were good at sorting out problems. There is a complaints procedure in place that shows the stage-by-stage process. There have been no complaints since the last inspection. The manager has provided POVA (protection of vulnerable adults) training for staff and residents alike. Restrictions placed on residents are fully documented and justified and have been sanctioned by appropriate professionals with resident knowledge and agreement. A shortfall, relating to this and standard 34, involves the recruitment process currently employed by the home. References and POVA checks are not being sought in advance of a new staff member commencing employment; greater details can be found in the staffing section. Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 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 standard(s) 24, 25, 26, 27, 28, 29, 30 The home is comfortable and safe with a homely atmosphere. Bedrooms meet individual needs and lifestyles and promote independence. There are sufficient toilets and bathrooms. Sufficient shared space freely is available. No resident requires specialist adaptations. The home is clean and hygienic. EVIDENCE: There is an ongoing maintenance and improvement programme in place, planned this summer is the landscaping of the front garden and full replacement of windows and frames to the rear of the house. Communal areas are decorated and furnished to a good standard and to the liking of the residents. The house is bright and airy throughout. The kitchen is spacious and leads to a dedicated utility room. An infection control procedure limits the spread of infection from laundry. Residents are encouraged to furnish their rooms with items of their choosing, and as such, one resident had a shortfall in furnishings that is being addressed through a goal plan. Rooms are decorated as each individual wishes. Staff benefit from a dedicated office that is also sufficiently large for a ‘sleep in’ room. Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 Recruitment procedures require improvement to ensure the safety of all residents. Training is provided to meet resident needs, but there are shortfalls in the area of medication. EVIDENCE: Recruitment procedures and practices are not as stringent as they need to be to protect residents from unsuitable personnel. A staff file was checked and they were found to have been in post in advance of their CRB (criminal records bureau) disclosure / POVA check being sent for and in advance of references being received. In this instance, no written references had been obtain, just telephone information. A long discussion ensued in respect of CRB timing and dispensation CSCI may have previously granted. It is unacceptable to habitually place staff in post without the minimum POVA disclosure and two written references from appropriate sources. Care Homes Regulations were amended in July 2004 (1770); review of the whole procedure against this amendment and the POVA guidance is required. There are many training opportunities for staff, and several courses also include the residents as participants. A full overview of staff skills was not obtained, but the manager advised that a matrix of training would be constructed. Identified in standard 20, staff administering medication before having received training from a qualified source must be rectified. Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41, 42 The home is well run in an inclusive manner. The ethos of the home is supportive, encouraging the development of the residents. Quality assurance measures are in place but could be improved. Policies and procedures are generally good, but previously identified areas (medication and recruitment) must be reviewed. Records are kept safe and secure and generally accurate, but one minor shortfall was found. The home is a safe environment for both residents and staff. EVIDENCE: The manager, Sharon, is a well-organised, efficient person who ensures residents are consulted as appropriate, in regard to life at the home. Sharon has completed the work towards the NVQ 4 / Registered Managers award and is awaiting direct assessment. Through conversation with a resident, it is clear that the ethos is to provide a positive, inclusive atmosphere for both staff and residents. Staff said that the management team were very supportive and would help with difficulties; offer training and additional support when required. There is a quality assurance procedure in place, by way of a Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 20 questionnaire. Unfortunately, parties outside the home have been reluctant to respond; therefore gauging the homes service in this way has not been as successful as the manager hoped. A recommendation is that the survey be condensed and simplified to (possibly) encourage a greater response. Policies and procedures are generally robust; all are subject to a review process every 24 months or sooner. From this report, it is required that the medication and recruitment policies are reviewed to reflect current legislation and good practice, as detailed earlier. All records seen were up to date and in good order, one minor shortfall forming a recommendation was that the duty rota state the staff full name and a key to the short codes used be added, to reduce any ambiguity when looking back at archives. Health and safety was well managed, with documented fire drills and checks in place. A resident was able to advise the procedure for evacuation and other health and safety matters regarding food hygiene. Accidents are logged and patterns monitored. Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 2 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 N/A 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 2 3 3 Standard No 31 32 33 34 35 36 Score x x x 1 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Birch House Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 3 x H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 22 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. 2. Standard YA1 YA20 Regulation 5 13 (2) 18 (c,[i]) Requirement Simplify service user guide to enable greater accessibility to residents. In reference to the Royal Pharmaceutical Society Guidelines; Staff to receive training from a qualified source prior to administering medication unsupervised. Handwritten MAR directions to be exact replica of the GP / pharmacists printed directions. Bolt medication cabinet securely to wall. In reference to Care Homes Regulations 2001 amendment 1770; Review recruitment procedure to ensure that service user safety is promoted. Review medication & recruitment policy and procedure to reflect current legislation and good practice. Timescale for action 01/07/06 01/08/05 01/07/05 01/07/05 01/08/05 3. YA23 & YA34 19 & schedule 2 4. YA40 13 (2), 18, 19. 01/08/05 Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 23 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 YA8 & YA15 Good Practice Recommendations Demonstrate a consultation process has taken place in respect of choice of holiday and decoration of the home. Where individuals from other homes visit and there is friction, this must be monitored and action taken to prevent the resident being placed in this position. Negotiate with pharmacist to supply medication for home leave. Add into to behavioral management strategies the point as required medication is considered. Create a training matrix for the staff team to enable a skills overview to take place - submit a copy to CSCI. Consider simplification of Quality Assurance survey and include the residents in the process. Duty rota should state staff full name and have a key to the short codes used. 2. YA20 3. 4. 5. YA35 YA39 YA41 Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Birch House H56-H05 S23198 Birch House V223430 060605 Stage 4.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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