Inspection on 12/10/07 for Bullpond Lane

This inspection was carried out on 12th October 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bullpond Lane 23/01/09

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Bullpond Lane 60, Bullpond Lane Dunstable Luton Beds LU6 3BJ Lead Inspector Mr Pursotamraj Hirekar Key Unannounced Inspection 12th October 2007 1:45 Bullpond Lane DS0000070212.V351545.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 Bullpond Lane DS0000070212.V351545.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. Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bullpond Lane Address 60, Bullpond Lane Dunstable Luton Beds LU6 3BJ 01582 472580 01582478875 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) londonroad@tiscali.co.uk Milbury Care Services Ltd Mrs Rebecca Jane Jackson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender Either Whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD The maximum number of service users who can be accommodated is 6. Na 2. Date of last inspection Brief Description of the Service: Bullpond Lane home is owned by Millbury Care Services, a subsidiary of the Paragon Healthcare Group. The company has been established for 17 years to provide residential care to people with challenging behaviours due to their complex needs. The home had been developed from a private property located in a residential part of Dunstable in Bedfordshire, in close proximity to local facilities (Dunstable town centre) and transport links. Bullpond Lane had six en-suite bedrooms - two of these were on the ground floor. Each was fitted with a toilet, hand basin, bath, and showerhead. The smallest bedroom, according to the home’s SoP was 12.4 sq m excluding the en-suite and the largest 24.05 sq m. All of the bedrooms had been individually decorated and included a bed, a chair a table, a touch operated lamp and matching curtains and bed linen. Service users would individualise their bedrooms with pictures and small items of furniture from home if they wished. In addition to the bedrooms the premises included a lounge, quiet room, conservatory, dining room, kitchen, laundry, office, a number of store cupboards, a downstairs toilet, a fully enclosed garden and parking for several cars to the front and side of the property. The home had been decorated and furnished to a high standard. A TV and 2 music systems were available for service users within the communal areas. Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the first unannounced inspection carried out on 12/10/07 by Pursotamraj Hirekar over 5 hours 55 minutes. The manager and the senior staff coordinated the inspection. The method of inspection included study of care plans, risk assessments, personnel records, staff deployment duty rota, relevant care delivery documents, discussions with manager and staff, conversation with service users’ and partial tour of the building. The annual quality assurance assessment self-assessment information provided by the home is included for analysis and preparation of this report as well. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure to complete assessment of all elements of health and personal care for all service users and are reflected in their individual care plans. The home must ensure that all service users individual specific risk assessments and risk management strategies are carried out and changes are reflected in the individual care plan as well. The home must ensure and evidence that all service users’ medication was carried out as prescribed and MAR sheet maintained with details explaining codes, as and when required. The home must ensure to carry out water temperature check to avoid any harm to service users. The home must ensure that adequate staff ratio and deployment is maintained all the time in response to the needs of the service users Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 6 including appropriate contingency plans to mitigate any staff member absences. The home must ensure that the action points agreed in the staff supervision meeting are actioned. The home must ensure that homes health & safety, and individual service users’ risk assessments are upto date, to ensure service users & staffs are protected from the risk of harm. The home must ensure that all staffs have clear responsibilities and follow the same in day-to-day work, to protect and promote the needs of the service users’. Each service user must be provided with an individual written contract or statement of terms & conditions. The home should evidence that the service user or a representative have participated in the assessment of needs of the service user. The home should ensure that all the service users’ are engaged in appropriate local, social, and community activities. The home should ensure that service user plans are in a suitable format for service users to understand with clear, outcomes, & objectives. Also ensuring that they are drawn up with the involvement of others, such as family, friends or advocates as appropriate. The home should ensure that information about the home including service user contracts & the service user’s guide, are available in formats suitable for each service user. 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. The summary of this inspection report can be made available in other formats on request. Bullpond Lane DS0000070212.V351545.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 Bullpond Lane DS0000070212.V351545.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had carried out pre-admission assessment of potential service users. However, needed further improvement to cover all the details involving service users or their representative. Also, the home must ensure that all the service users’ have written contracts. EVIDENCE: The homes service user guide provided information to enable prospective service users to make an informed choice about where to live. However, the service users guide to be more users friendly to meet the communication needs of the service users. There was evidence that the home had assessed the needs of the service users, the home was able to demonstrate that it could meet the assessed needs of individuals admitted to the home. However, the documentary evidence of this had not been completed in full and date of admission was not recorded. 2 service users or their representative, whose lives were tracked as part of this inspection process, had not signed them. Service users’ individual contracts were not provided on this inspection. Bullpond Lane DS0000070212.V351545.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user plans and individual risk assessments were incomplete. Further development was needed to ensure they supported each other’s information and that they contained all relevant information, drawn up involving service users and others as appropriate, in a suitable format for the service users to understand. Therefore minimising risk to service user’s and supporting them to understand and participate in decisions about their needs and personal goals. EVIDENCE: The current individual support plan tool that the home had used for assessment and preparation of service users’ care plan covered information about personal information, support requirements, likes and dislikes, risk assessments, behaviour guidelines, reviews and assessments, goals and ambition, social activities, health, incidents, daily service records, monthly reviews, contact sheet and after death wishes. However, the home had now planned to introduce a revised individual specific support plan tool for all the service users’ from November 2007. The revised support plan is comprehensive and appeared user friendly. The tool covered Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 10 information relating to individual service user in two broad areas personal information and plan of support/support plans/risk assessments. The personal information covered; personal details, description of me, family and friends, professional support networks, preferred daily routine, likes and dislikes, interest and hobbies, weekly plan, communication, health, medication, allergies, diet, and financial information. The plan of support/support plans/risk assessments; covered information about physical health, communication, personal care, mobility, social skills, finances, relationships, activities and holidays, living skills, behaviour, cultural and spiritual expression, medication, decision making, ageing, illness and death. A sample of the service user’s plans and supporting documentation were examined and found to contain insufficient information to help meet their changing needs and personal goals which needed to be reflected in their individual plan. Further development was required in some areas, as some goals, ambitions, and risk assessments were incomplete. Service user –1 had 12 incidents of assault on staff and others form 31/07/07 to 15/09/07 and there has been no specific risk assessment carried out by the home. Service user – 2 ran to family home without informing staff on duty on the 02/07/07 and there was no risk assessment carried out by the home. The individual service user or their representative had not signed each service user’s plan. Monthly reviews was incomplete and had not been reviewed which could not provide adequate support for carers to follow. The manager informed on the inspection that the care plans were schedule for review every 6 weekly, 3 monthly, 6 monthly and yearly. Service users were supported by an advocacy service if they wished. There was evidence from observing, speaking with service users and records examined that service users were assisted as necessary to make decisions about their daily lives. Service users were observed participating in daily routines of the home and service user meetings are held within the home and documented. There was evidence that detailed daily service records of service users have been maintained for AM, PM and night. Bullpond Lane DS0000070212.V351545.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home and staff support the service users to pursue meaningful leisure activities, relationships, & community links. EVIDENCE: Service users were supported and provided with the opportunity by staff to fulfil their spiritual needs, some service users were supported to visit church when they requested to. It was evident that service users were given the opportunity for personal development. The home had planned detailed activities for the service users that were presented in a weekly format day wise. The home in consultation with the service user had detailed various activities for the service user which included college, day services, badminton, bowling, dominoes, films, games, TV, room cleaning, walk, and support to maintain relationship with family members. The planned service users’ activities were compared with today’s actual situation and found that the service users’ were engaged as planned for the day. However, service user - 1 who was schedule to attend youth club today was at the home, the manager Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 12 informed that the home was in the process of planning to set up yoga classes as an alternative. Service user – 2 was supported to Accesses College 4 days a week, 1 day a week based at the home completing household tasks, shopping and relaxing. The other leisure activities in which service user was engaged included; spending time with friends, swimming, bowling, cinema, pub, singing, walking, and shopping. The home had made appropriate arrangements for the service user to contact and visit family. There was evidence that the home supported service users to maintain family links and friendships inside and outside the home, in accordance with their wishes and service users spoken to confirmed this. Service users were offered a choice of menus and were actively supported to help plan meals. The menu’s choices were in a suitable format for service users to make an informed choice and decide what they would like to eat. Bullpond Lane DS0000070212.V351545.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a suitable medication policy and staff had received satisfactory training in medication administration. However, the delivery of the medication systems within the home required some improvements, to safeguard the wellbeing of the service users, to prevent placing them at potential risk. EVIDENCE: Service users spoken to said they enjoyed living at the home and that they felt supported by the staff. Records viewed suggested service users received personal support in the way they preferred and most were encouraged to maximise their independence. This was supported by observations and discussions held with service users. Those service users spoken to said they were happy with the support from the staff and the relationship they had developed with them. There was evidence that the home accessed outside healthcare professionals and services as required; in order to meet the healthcare needs of the service users. Service users were supported by the home to attend outpatient and other appointments. Samples of medication records, storage, and procedures were checked, of those service users whose lives were being tracked as part of this inspection. Staff administering medication was observed in part. Staff had Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 14 received satisfactory training in medication administration. No service users were responsible for administering their own medication within the home. The homes procedures for the administration of medication in some areas required some improvements, to reduce the potential risk of errors taking place and therefore placing service users at risk. Service user –1 application of metosyn ointment to scalp margin was recorded as F that meant other (define), and what F meant was not defined. Betnovate RD ointment in 5 LPC apply twice a day when required was blank on the MAR sheet, when enquired the manager informed that the cream was not received as yet and awaiting confirmation from the GP. Service user –2-lunch time medication and weekend medication was recorded as D on the MAR sheet, which meant social leave. There was no clarity on the MAR sheet what social leave meant. On an enquiry the manager informed that the lunchtime medication was administered at Townsend, and the family administered the weekend medication. However, it was not enough to simply record D on the MAR sheet but the home must evidence that the service user was administered medication as prescribed. Bullpond Lane DS0000070212.V351545.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for protecting service users were satisfactory. EVIDENCE: A record was kept of all complaints. The home had a satisfactory complaints policy and procedure in place, which enabled them to deal with complaints received. All service users are spoken to as part of this inspection said they had no complaints to make and were happy. The home had a Safeguarding Vulnerable Adults (SOVA) policy in place, which included whistle blowing and staff spoken to said they were aware of the procedure. Several staff had also attended SOVA awareness training. The home had received a complaint from the family member of a service user - AM, which was dealt with appropriately using the home’s policy and procedures. For example, a complaint that was received on the 31/08/07 was investigated on the 03/09/07 and a meeting was held on the 11/09/07 with the service user, mother of service user, advocate, manager, service manager, and social worker. Following the above meeting a review was undertaken on the 28/09/07. However, the review document was not seen on this inspection, as it was yet to be received from the social worker, the manager informed. The changing needs and reviewed care provision need to be reflected into the care plan, the manager was aware of this. The homes policies and practices regarding service users money and financial affairs were generally satisfactory and protected service users from abuse. Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Since October 2007 the water temperature checks were not carried out placing service users at risk of scalding. EVIDENCE: The home was close to local amenities and transport if required. One service user said that they had everything they needed and wanted in their bedroom. Another service users bedroom was observed to reflect their needs and lifestyle. All rooms were single occupancy with en suite provision. Service users spoken to were clearly happy with their individual bedrooms and were encouraged to take responsibility to maintain their cleanliness. Kitchen platform has been extended and EHO report dated 25/05/07 described the home as good. Toilets and bathrooms appeared adequate and provided sufficient privacy. There was evidence that the environment had been well maintained. However, the water hot temperatures were regularly recorded until September 2007 and for the month of October 2007 were outstanding placing service users at risk of scalding. There was evidence that the manager had discussed this with the Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 17 staff responsible on the 10/10/07. However, this has not been actioned as on this inspection. The homes outdoor space appeared adequate. The home had adequate washing facilities. The home appeared clean and free from offensive odours, service users, care staff and night staff were responsible for ensuring this was maintained. It was apparent from the records presented by the home that the home had carried out general risk assessments of the premises that covered; dining room, living room, kitchen, conservatory, garden, quiet room, laundry room, toilet, bathroom’s, vehicle, bathing of service user, access to loft, using lawn mover, using trimmer, barbecue, and kitchen safety. Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home need to have adequate contingency measures to maintain adequate staffing ratio all the time and ensure the action points discussed in the staff supervision meetings are implemented, without putting the service users at risk of harm. EVIDENCE: Staffing level numbers within the home were maintained to meet the appropriate ratio based upon the needs of the service user. The home had a 3shift staff deployment rota, 7.00am to 2.00pm shift had 2 staff members, 2.00pm to 9.00pm shift had 3 staff members, and 9.00pm to 7.00am shift had 1 sleep in and 1 waking staff. However, on the 09/10/07 for the 2.00pm to 9.00pm shift there were only 2 staff members deployed. The home needs to look into issue of staffing ratio and their deployment and have appropriate contingency plans in place. Staff files that were examined, demonstrated that the home had obtained satisfactory checks and clearances on staff before their commencement, therefore the home was able to demonstrate that service users were protected by the home’s recruitment policy and practices. Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 19 The home was able to access a structured corporate training plan. Which offered them the opportunity to nominate staff to attend varied statutory and specialist training, relevant to their roles and service user’s needs. The home’s training register which, was examined, evidenced staff that had attended training events since May 2007 which included, safeguarding adults, fire, epilepsy, medication, first aid, moving and handling, health, & safety. staff had attended training in learning disabilities and mental health, abuse & challenging behaviour and food safety. Staff spoken to and records examined, provided evidence that staff received supervision. However, bank staff member was scheduled for supervision from October 2007. The home need to have appropriate measures in place to ensure that the action points agreed in the staff supervision are implemented with out putting service users at risk of harm, in this case the water temperatures that was discussed in a supervision meeting was not actioned as on this inspection. Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some aspects of the homes health & safety, and individual risk assessments needed further development to ensure service users & staff would be protected from the risk of harm. EVIDENCE: The manager was present during part of this inspection. The manager demonstrated that she possessed the knowledge, skills, and experience to run the home. Developing and maintaining an effective quality assurance system within the home had been implemented through regulation 26 visit by the operations manager and monthly residents meeting. However, the home should ensure that all service users are involved. There was evidence that the home maintained general risk assessments, including health & safety and fire. Various records were examined to support adequate compliance with the following safe working practices, regarding health & safety including; accident records, water temperature checks and fire Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 21 test and inspection records. However, the hot water temperature checks were not carried out from October 2007 please refer environment outcome group of this report for details. Individual Service users’ risk assessment must be carried out as and when situation arouse – please refer under individual needs and choices outcome group of this report for details. On this inspection, 2 service users’ monies management by the home was seen and found that the individual cash balances and the records tally. However, on few occasions the support staffs has only signed the service user money transaction. The home may consider authorising the support staff or having a counter signature by the manager when service users’ money transactions is managed by a support staff. Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 22 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 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 2 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 23 NA 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) Requirement The home must ensure to complete assessment of all elements of health and personal care for all service users and are reflected in their individual care plans. The home must ensure that all service users individual specific risk assessments and risk management strategies are carried out and changes are reflected in the individual care plan as well. The home must ensure and evidence that all service users’ medication was carried out as prescribed and MAR sheet maintained with details explaining codes, as and when required. The home must ensure to carry out water temperature check to avoid any harm to service users. The home must ensure that adequate staff ratio and deployment is maintained all the time in response to the needs of the service users including DS0000070212.V351545.R01.S.doc Timescale for action 30/11/07 2. YA9 15(2) 30/11/07 3. YA20 13 (2) 01/11/07 4. YA24 13 (4) 15/10/07 5. YA33 18 30/11/07 Bullpond Lane Version 5.2 Page 24 6. YA36 18(2) 7. YA42 23 (2) (p) 8. YA31 19 9. YA5 5 (1b) & (1c) appropriate contingency plans to mitigate any staff member absences. The home must ensure that the action points agreed in the staff supervision meeting are actioned. The home must ensure that homes health & safety, and individual service users’ risk assessments are upto date, to ensure service users & staffs are protected from the risk of harm. The home must ensure that all staffs have clear responsibilities and follow the same in day-today work, to protect and promote the needs of the service users’. Each service user must be provided with an individual written contract or statement of terms & conditions, which must include the amount and method of payment of fees. 15/10/07 30/11/07 15/10/07 30/11/07 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 YA2 Good Practice Recommendations The home should evidence that the service user or a representative have participated in the assessment of needs of the service user. The home should ensure that all the service users’ are engaged in appropriate local, social, and community activities. The home should ensure that service user plans are in a suitable format for service users to understand with clear, outcomes, & objectives. Also ensuring that they are drawn up with the involvement of others, such as family, friends or advocates as appropriate. The home should ensure that information about the home DS0000070212.V351545.R01.S.doc Version 5.2 Page 25 2. 3. YA12 YA6 4. YA1 Bullpond Lane including service user contracts & the service user’s guide, are available in formats suitable for each service user. Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Bullpond Lane DS0000070212.V351545.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!