Inspection on 11/01/07 for Bishops Corner

This inspection was carried out on 11th January 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bishops Corner 15/11/05

Bishops Corner 09/05/05

Bishops Corner 24/11/04

Bishops Corner 29/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Bishops Corner 23 Boscobel Road St Leonards-on-sea East Sussex TN38 OLX Lead Inspector Caroline Johnson Key Unannounced Inspection 11th January 2007 09:30 Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bishops Corner Address 23 Boscobel Road St Leonards-on-sea East Sussex TN38 OLX 01424 201643 01424 421684 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) New Directions (Bexhill) Limited Mrs Teresa Hills Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is eight (8) Service users must be aged between eighteen (18) and sixty-five (65) years on admission Service users with a learning disability only to be accommodated Service users with Prader Willi Syndrome may be accommodated Date of last inspection 15th November 2005 Brief Description of the Service: Bishops Corner is a care home providing social and residential care for eight young adults with learning disabilities, in particular those with Prader-Willi syndrome. The home is owned by New Directions (Bexhill) Limited who also have another two similar homes in East Sussex. It is situated in a quiet residential part of St. Leonards-on-Sea, being a short walk from the town’s shopping centre and railway station. The house is a large three-storey property. There is a garden with patio terrace for use by residents at the rear of the house. Accommodation is provided on two floors. There are two communal lounges, one designated for smokers, and a separate dining room. The domestic-style kitchen and laundry are suitably equipped. There is a large arts and crafts room, which is in daily use by service users, supervised by day centre staff. A variety of off-site activities are arranged, including attendance at the local college and sports centre. A people carrier vehicle is available for trips and leisure outings. The range of fees as of August 2006 is £1035 to £1538 per week. Additional charges are made for hairdressing, toiletries, magazines and papers and some transport. Inspection reports can be read at the home and reference to how to obtain a copy is also made in the home’s statement of purpose. Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the inspection process a site visit was carried out on 11 January 2007. The visit lasted from 09.30am until 3.20pm. Over the course of the visit there was an opportunity to share lunch with five of the residents. One of the residents took the inspector on a tour of the communal areas and their individual bedroom. There was also an opportunity to meet with the director, the deputy manager and with two care staff. A wide range of documentation was examined including care plans, records held in relation to medication, fire safety, staff recruitment, staff training, staff rotas and health and safety documentation. At the time of the site visit the registered manager was on maternity leave and the deputy manager was working as acting manager. Attempts were made to contact three relatives but contact was only made with one of them. Feedback received was very positive and included ‘the routine needs of the client group at met, and the home are good and effective at managing both weight and behaviour issues. The staff team change from time to time but this is managed well’. They also said that if ever they have a problem, which is very rare, they do not hesitate to pick up the phone, as they know from experience that issues are dealt with and action taken to resolve matters. They stated that the one area that they felt that some improvement could be made, they had discussed recently with the home and this involved their relative having a clearer sense of direction in relation to their long-term future. The Company has acknowledged that they need to review their care plan process. Similar issues have been raised in the other sister homes. However as the inspections for all three homes have been close together and Christmas has also fallen within this period this has not given them time to address this issue yet. It is recognised that for this piece of work to be addressed effectively it needs to be researched, planned and implemented over a period of time. What the service does well: In comment cards distributed prior to the inspection some of the views written by the residents were very positive with comments like ‘staff are nice to me’, ‘staff help me lots’ and ‘the staff are nice and helpful when I need help’. Residents spoken with during the site visit stated that they like living at Bishop’s Corner. Staff also spoke very positively stating that the acting manager is `very supportive’,’ always there if you need to chat’ and `the staff work well as a team’. There is a very good programme of activities in place for the residents, with good opportunities for their personal development. Programmes include a lot of variety and when residents suggest new ideas these are explored. An example of this was one resident stating they would like to join a salsa class. Arrangements were made for this to happen and it is now a regular occurrence. Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 7 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 Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 8 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 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. There is detailed information available in the statement of purpose about the home and the facilities on offer. The statement needs to be updated to reflect the current management arrangements for the home. EVIDENCE: The statement of purpose needs to be updated to reflect the changes to the management team. A good practise recommendation was made at the last inspection that resident review records be signed, by the person completing them. No reviews have been held since the last inspection so this will be followed up at the next inspection. There have been no new admissions to the home since 2003. As part of the updating of the care plan process all of the residents’ needs and abilities will be reassessed. Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 9 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): 6,7,9 Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. The company acknowledges the action required in relation to updating the care planning system so that each resident’s goals are specific, measurable and achievable and risks are explicit with detailed advice on the action to be taken to minimise the risk of accidents/incidents occurring. By updating the care planning process, this would mean that the home could capture more clearly the progress each individual is making in terms of development of new skills and experiences. EVIDENCE: The director advised that the care planning process would be revised following recent recommendations made following inspections of the other homes within the company. As a result emphasis was not placed on examining care plans at bishop’s Corner. Two care plans were briefly examined and it was noted that issues raised at this site visit were similar as in the other homes and include the need to have goals that are specific, measurable and achievable. In addition in relation to risk assessments the risks need to be more explicit Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 10 detailing the action required to minimise the risk of an accident/incident occurring. Residents spoken with advised that they are able to make choices and decisions about how they spend their time and about their home. Choices include where they want to go on holiday and how their rooms are to be decorated. The residents also make daily choices/decisions such as the clothes they wear and the way they have their hair done. Staff were observed offering residents choices about how to spend the afternoon. Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 11 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): 12,13,15,16,17 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home is good at ensuring that residents remain active and attend stimulating and rewarding activities. They are keen to explore new ideas for activities especially when the suggestions come from the residents themselves and to ensure that each resident’s programme remains varied and interesting to the residents. EVIDENCE: Some of the residents have work placements, some attend college courses and some attend one of the two-day centres run by the company. Activities that residents participate in include, gym, swimming, bowling, pottery, basketball, horse riding and trampoline. Pottery sessions are run twice a week in Hastings. Residents also attend a numeracy and literacy class two mornings a week. It was reported that one of the residents recently asked to go to a salsa class and that arrangements were made for this to happen and it is now a Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 12 regular occurrence. Some of the residents have also expressed an interest in line dancing so this is now being explored. Arrangements are also made for residents to visit and receive visits from friends for lunch and evening meals. A number of the residents have relatives who visit on a regular basis and where necessary staff support residents to maintain contact. Last year there was a holiday to Butlins and it was reported that this year residents have expressed an interest in going to Center Parcs. The director reported that she had recently purchased a new policy on food safety and nutrition. This was not available for inspection so this will be seen at the next inspection of the home. The meal produced on the day of inspection consisted of sausages, potatoes and beans. Menus seen show variety and are well balanced. There is a choice of meal served at lunch and at supper. A cooked breakfast is served on Sundays. All meals are calorie counted so if there is overindulgence in one area this is compensated for at the next meal. The residents spoken with stated that they arrangements work well for them. Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 13 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 (good) This judgement has been made using available evidence including a visit to this service. The home is good at ensuring that the healthcare needs of the residents are met and at ensuring that specialist advice and support is enlisted when needed to meet each resident’s individual needs. EVIDENCE: Records were seen in relation to medication administered to residents and they were in order. Only senior staff have responsibility for administering medication. Records showed that staff have received training on the subject although one member of staff is due to attend training to update their knowledge. The home supports residents to attend a wide range of healthcare appointments such as chiropody, dentist, opticians and also more specialist appointments via the hospital. At the time of inspection one resident was receiving support from the local Community Learning Disability Team and a referral had been made for another to receive support. Staff observed in the course of their duties were courteous and friendly and the residents responded well to staff. Over the course of the visit there were times when residents required emotional support with particular issues that Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 14 were bothering them and in all cases staff responded professionally and gave clear and consistent advice/support. Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 15 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. Overall there are good procedures in place to ensure that residents can raise concerns and that when they do action is taken to resolve them. The home needs to ensure that they always record how they have investigated concerns and that they have responded to the complainant. As this was missing in only two out of eight complaints this should not affect the overall rating for this category. The procedures in place for the reporting of adult protection issues are detailed and adhered to by staff. EVIDENCE: Records showed that eight complaints had been made. There was detailed information obtained from the complainants along with the proposed action to deal with the issues raised. In most cases the investigation process was documented but in two cases it was not clear how the complaint had been investigated and if the complainant had been informed of the outcome. No complaints have been made to the Commission about this service since the last inspection. One resident expressed some difficulty working with some staff members at times. The resident was aware of the home’s complaint procedure but was unsure whom to complain to outside of the organisation if the problem persisted. This was explained to them. They agreed to follow the home’s complaint procedure initially to see if they could resolve the problems. There were twelve adult protection alerts within 2006. Records showed that the relevant authorities were satisfied with the information received in each case and with the risk assessments and guidelines in place to minimise the risk Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 16 of reoccurrences of similar incidents. The majority of the staff team have had training on the subject of adult protection and prevention of abuse. Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,28,30 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Bishops Corner is well maintained and is decorated to a good standard. There are good measures in place in relation to fire safety. However, in relation to one resident who often refuses to leave the building when the alarms sound there should be a risk assessment in place detailing the action to be taken by staff on these occasions. EVIDENCE: A full tour of the building was not undertaken on this occasion. However one of the residents took the inspector on a tour of the kitchen, dining room, lounge, smoke lounge and their bedroom. Garden areas were also seen. All areas were clean and there were no unpleasant odours. Over the course of the lunch period one of the residents stated that their bedroom was cold at night and asked the director if the radiator could be examined. The acting manager also confirmed that she would check to see if the resident had enough bedding at night. Another resident also asked if they could have an electric blanket. The director advised that if following a risk assessment it was considered appropriate to have an electric blanket, this would be arranged. This resident Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 18 also asked for a shelf to be fitted to their room. The acting manager advised that this would be arranged. A requirement was made at the last inspection that towels in bathrooms and toilet areas be replaced with a single use method for hand drying. Small hand towels for single use are now used and washed on a daily basis. In relation to fire safety, records showed that alarms and emergency lights are checked in line with the home’s policy. Fire drills are carried out on a regular basis. It was noted that two of the residents occasionally refuse to leave the building when the alarms sound. There is a risk assessment in place in relation to one of these individuals. The acting manager agreed to draw up a risk assessment in relation to the second resident. Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home’s recruitment practices are good ensuring that staff are vetted thoroughly prior to allowing them commence work in the home. There are also good training opportunities available to staff ensuring that staff are well qualified to meet the needs of the residents in their care. EVIDENCE: It is reported that there is always a minimum of one staff to four residents but that these staffing levels are often exceeded. In addition to the acting manager, there are three senior staff, one full-time and one part-time activity co-ordinator and a large support team. Records showed that all staff receive regular training opportunities and, with the exception of the newest recruits, staff were up to date with mandatory training. Staff do not attend a formal training session on infection control but it was reported that this topic is covered in detail during induction. Two of the staff team have NVQ level 2 and five of the staff team have NVQ level 3. Another member of staff spoken with stated that they hoped to commence training for an NVQ in the near future. Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 20 Since the last inspection there has been a high turnover in the staff team for a variety of reasons. With the exception of one night shift all positions have been filled. The night shift vacancy had been advertised. Recruitment files were examined in respect of two recently recruited staff. In both cases the home had taken up all the necessary checks. POVA first checks had been obtained and the home were awaiting confirmation of the full CRB checks. In the interim they confirmed that staff work under supervision. All new staff work through a very detailed induction package. This involves an intense twoday induction and then completion of the Common Induction Standards within a twelve-week framework. The acting manager advised that she meets with new staff regularly during their induction period. All staff receive regular supervision and staff spoken with confirmed that supervision is received every six weeks. Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42,43 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home continues to be managed well, staff are well supported and the acting manager is also well supported. Quality assurance audits are carried out regularly and the findings are analysed. Health and safety issues are addressed but the record keeping is not always clear as to whom the issues have been referred to and how long it took to address the issue. Although this information should be clearer and a recommendation will be made this should not affect the overall quality rating for this section. EVIDENCE: The registered manager is currently on maternity leave and, in the interim the deputy manager is working as acting manager. The acting manager advised that she has almost completed NVQ level three and that on completion she intends to study for NVQ level 4 and the Registered Manager’s Award. Staff spoken with stated that the home is run well and that the acting manager is `very supportive’,’ always there if you need to chat’ and `the staff work well Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 22 as a team’. It was reported that staff meetings are held regularly and that one of the residents sits in on part of the meeting to represent the residents’ views. Records for staff meetings were not seen and this will be followed up at the next inspection. As part of the quality assurance system satisfaction questionnaires are sent to residents, their relatives, the staff team and to visiting professionals. A good response was received following a recent survey. The acting manager advised that she would now analyse the responses and advise all relevant people of the comments received and any action taken as a result. A number of questionnaires were seen and comments were very positive. Prior to the site visit comment cards were sent to the home for distribution to the residents. Although six responses were received one of the six had chosen not to complete the form. Two of the residents received support from a relative to complete the form. Responses were generally very positive with comments like ‘staff are nice to me’, ‘staff help me lots’ and ‘the staff are nice and helpful when I need help’. Two residents stated that they didn’t know what to do if they wanted to make a complaint. The acting manager confirmed that this has been clarified following the last inspection but that they will do it again. Another resident stated that sometimes they ‘can’t get out because there are not enough staff on and its boring when not enough staff on’. Another stated that they ‘want to work towards more independence’. Feedback on the information received was provided to the manager. It should be noted that comment cards were completed in August and because of the staff turnover this could have affected activities. It was reported that this is no longer a problem. As part of the inspection process attempts were made to contact three relatives of the residents. Contact was achieved with one relative. They spoke very positively about the home and the staff team. Comments included, ‘the routine meets the needs of the client group, and the home are good and effective at managing both weight and behaviour issues. The staff team change from time to time but this is managed well’. They also said that if ever they have a problem, which is very rare, they do not hesitate to pick up the phone, as they know from experience that issues are dealt with and action taken to resolve matters. The one area that they felt that some improvement could be made they had discussed recently with the home and this involved their relative having a clearer sense of direction in relation to their long-term future. In relation to health and safety records showed that there is a very detailed checklist carried out on a monthly basis. Each area of the home is checked and issues that need attention are highlighted. However, it is not always clear who has responsibility for addressing the issues raised. There were a range of certificates in place showing that equipment is serviced on a regular basis. Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 23 The acting manager advised that the support systems in place for her whilst the manager is on leave have been very good and that the senior management team have been very supportive and constructive with their advice. In addition there are managers’ meetings held regularly which act as another point of support. Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 24 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 2 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 2 3 Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 25 NO 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 15(1,2) Requirement Care plans must be updated showing a revised assessment of each of the residents’ abilities and needs and clear goals that are specific, measurable and achievable. Risk assessments must be explicit detailing the level of the perceived risk (i.e. high/med/low) along with the action to be taken to minimise the risk of an accident/incident occurring. In relation to one resident a risk assessment must be drawn up detailing the action to be taken by staff should this resident refuse to leave the building in the event of a fire. Timescale for action 15/05/07 2. YA9 13(4) 15/03/07 3. YA24 23(4c(iii)) 31/01/07 Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 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. 2. 3. 4. Refer to Standard YA1 YA3 YA22 YA42 Good Practice Recommendations The statement of purpose should be updated to reflect the changes in the management team. That resident review records are signed by the person completing them. [Not assessed at this inspection] In relation to two complaints seen, records should show details of the investigation procedures taken and that the complainant has been contacted with the outcome. Where issues are highlighted in relation to maintenance, it should be clear whom the issue has been reported to and when action was taken to resolve the issue. Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 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 © 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 Bishops Corner DS0000021416.V309778.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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