Inspection on 27/06/06 for Bybuckle Court

This inspection was carried out on 27th June 2006.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bybuckle Court 25/09/08

Bybuckle Court 03/07/07

Bybuckle Court 13/09/05

Bybuckle Court 14/04/05

Bybuckle Court 02/09/04

Bybuckle Court 29/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Bybuckle Court Marine Parade Seaford East Sussex BN25 2PZ Lead Inspector Nigel Thompson Unannounced Inspection 27th June 2006 09:30 X10015.doc Version 1.40 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 Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bybuckle Court Address Marine Parade Seaford East Sussex BN25 2PZ 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) 01323 898094 Mr James Lord Mrs Sylvia Lord Mrs Sylvia Lord Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is seventeen. 13th September 2005 Date of last inspection Brief Description of the Service: Bybuckle Court is an established home providing residential care for up to seventeen older people. It is a large detached property, overlooking the seafront in Seaford and within easy walking distance of the town centre shops, amenities and railway station. Service users accommodation comprises fifteen single rooms and one double room, situated on two floors. The majority of the rooms have en-suite facilities, including a toilet and washbasin and all are fitted with a call bell system. On the ground floor there is a large, light and spacious lounge and dining area. A shaft lift provides access to the first floor. In addition to Bybuckle Court, the proprietors own a second home in Seaford, Hillersdon Court, which also provides residential care for older people. Information about the service, including the Statement of Purpose, Service User’s Guide and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. The range of weekly fees, as of 27 June 2006, is £310 - £400. Additional charges, not included in the fees, include hairdressing, chiropody, toiletries and newspapers. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five and a half hours in June 2006. It found that the majority of the National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Service users spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. On the day of the inspection there were thirteen service users living at the home. The inspection involved a tour of the premises, examination of the home’s records and discussion with the Acting Manager and newly appointed Deputy Manager. Responses from a CSCI service users’ survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. Five service users and three members of care staff were also spoken with. The focus of the inspection was on the quality of life for people who live at the home. What the service does well: What has improved since the last inspection? Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 6 Improved information is now available to prospective and existing service users in various formats, including the updated Statement of Purpose and the recently developed and overdue Service User Guide. As recommended, since the previous inspection, the acting manager now ensures that service users sign their individual written contract, including terms and conditions of residency, provided to each of them on admission to the home. Since the last inspection, as required, formal staff supervision has been introduced – regular and structured one-to-one meetings with individual care staff and their manager – to ensure that staff have the appropriate skills, knowledge and understanding of service users’ individual care and support needs. Monthly, unannounced visits by the proprietor have now been formalised, to ensure that she is kept aware of any significant issues or changes within the home, including the welfare and ongoing care needs of service users. Following these visits, as required under Regulation 26, the proprietor also compiles a report of her findings and submits a copy to the CSCI. What they could do better: As part of a structured and consistent admission procedure, it is essential that service users are only admitted to the home on the basis of a full needs assessment, carried out by a person suitably qualified and competent to do so. Service users must be protected from abuse by appropriate staff training and robust policies and procedures, which the staff are aware of and adhere to. Outstanding from the previous inspection is the need for safe, suitable and accessible outdoor areas to be provided for service users and be kept appropriately maintained. To ensure that staff have the relevant knowledge and skills to meet the care and support needs of service users, it is important that all staff receive a structured induction programme and training appropriate to the work they perform. Staff must also be aware of and adhere to policies and procedures, ensuring the health, safety and welfare of service users and receive appropriate training, including fire safety. Fire safety systems and equipment must be checked regularly and all parts of the home, to which service users have access, need to be free from hazards to their safety, including door wedges. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The admission process and documentation, including a comprehensive ‘Statement of Purpose’ and ‘Service Users’ Guide’ ensures that prospective service users and their relatives have sufficient information about the home and the services provided to make an informed choice about where to live. EVIDENCE: Information is available to prospective and existing service users in various formats, including large print. The recently updated Statement of Purpose and the Service User Guide have been produced to a high standard and are both comprehensive and informative. The acting manager confirmed that prospective service users are invited to visit the home to look around and meet with staff and existing residents. They often stay for lunch and are able to ‘generally get a feel for the place’. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 10 It was noted that the service users’ formal Contract/Terms and conditions of residence has been reviewed, as required, since the last inspection. There was evidence, in the cases of service users recently admitted to the home, that contracts had been issued to and signed by the individual themselves or a relative or representative on their behalf. Although there was evidence in some service users’ care plans of preadmission assessments having been carried out, there was not one in place in respect of a service user recently admitted to the home. This was discussed with the acting manager, who is to ensure that prospective service users are comprehensively assessed prior to moving into Bybuckle Court. The format for recording assessments is to be reviewed and restructured, as discussed and amended to include details of when the assessment was carried out and by whom. Service users, spoken with during the inspection, commented positively about their experiences of moving into the home: ‘I’ve been here since November and am very settled and very happy. I don’t need much doing as I’m fairly independent’. The acting manager confirmed that Bybuckle Court continues to have a contract with East Sussex County Council, to provide two respite beds. However emergency or unplanned admissions are not accepted and intermediate care is not provided. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users’ individual care plans enable staff to meet their assessed needs in a structured, consistent and respectful manner. The systems for service user consultation and participation are satisfactory and service users are protected by thorough procedures for the control and safe administration of medication. EVIDENCE: Individual care plans that were examined show areas of significant improvement since the last inspection, particularly in the level of detail regarding action to be taken by staff. Consequently the identified care and support needs are now being met in a more structured and consistent manner. There was also evidence that plans are regularly reviewed, with the involvement of service users and updated to reflect an individual’s changing needs. Staff spoken with during the inspection confirmed their awareness of the content of individual care plans and their involvement in the planning process. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 12 All service users are registered with local GPs and have access to other health care professionals, including district nurses, via the surgeries. It was noted, in care plans that were examined, that all appointments with, or visits by, health care professionals are recorded. Satisfactory policies and procedures are in place for the control, storage, safe administering and recording of medication. Following risk assessments, the acting manager confirmed that there is currently no service user with responsibility for self administering their medication. Through direct observation and discussion, it is clear that staff are aware of service users’ privacy and dignity. Members of staff were seen knocking on doors before entering service users’ rooms and were observed to be sensitive and respectful in their manner. Service users, spoken to during the inspection, expressed a high level of satisfaction with the care and services provided: ‘It’s first class here. At night there is always someone looking in to see if we’re alright’. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users maintain contact with family and friends as they wish and benefit from a weekly activities programme and from good quality menus that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: Service users’ care plans were found to contain details of the individual’s social and recreational interests. There are evidently a choice of activities that service users continue to have the opportunity to be involved in, including bingo, board games and quizzes, gentle exercise, indoor bowls and walks along the seafront. Service users are made aware of the activities available on a board displayed in the main entrance hall. Service users’ level of contact with their family and friends is variable, however, the acting manager confirmed that visiting to the home is unrestricted. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 14 The acting manager also confirmed that wherever possible, service users are enabled and supported to make choices and take decisions affecting their life and daily routines, including activities and menu planning. This was supported through discussions with the cook and service users. The experienced cook regularly consults with service users regarding their likes ad dislikes and ensures that they receive a varied, wholesome and nutritious diet. At lunchtime a choice of main meal is available and special diets are catered for. As part of a four week rolling menu, a weekly menu is displayed in the main dining area, reflecting service users’ preferences and including seasonal variations. Service users, spoken with during the inspection commented favourably on activities and the quality of the meals provided: ‘It’s lovely here. We go down for our meals and to play bingo’. ‘The food is exquisite’. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The open and inclusive atmosphere within the home enables service users, staff and visitors to feel able to express any concerns, confident that they will be listened to and acted upon. However, service users are at potential risk from abuse, through inadequate staff training and unsatisfactory policies and procedures. EVIDENCE: A clear and accessible complaints procedure has been produced and is in place in the entrance hall. Service users and members of staff spoken with during the inspection, confirmed that they would have no hesitation in speaking to the acting manager or making a complaint if necessary and each person was confident that they would be listened to. Policies and procedures relating to abuse and including whistle blowing are in place, however they were found to be unsatisfactory and must be reviewed. Inaccurate and outdated procedures refer to alerting the NCSC (National Care Standards Commission – the regulating body that preceded the CSCI.) Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 16 The acting manager confirmed that abuse training is not currently provided for staff. This was also evident through training records that were examined and confirmed by members of staff, spoken with during the inspection. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from accommodation that is safe, comfortable, generally well maintained and decorated to a satisfactory standard. EVIDENCE: There has been steady improvement to the physical environment at Bybuckle Court since the previous inspection, including the redecoration of two service uses’ rooms, new carpets fitted in several bedrooms and new floor covering in the kitchen. New comfortable chairs for the lounge and a dishwasher have recently been provided for the home and the acting manager confirmed that a replacement carpet for the ground floor bathroom is on order and is due to be fitted soon. On the day of the inspection, decorators were completing work on the outside of the building, painting the rear of the premises. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 18 Service users’ rooms were found to be generally clean, comfortable and well maintained. The acting manger confirmed that residents are encouraged to personalise their room and are able to bring in pictures, photographs and small items of furniture. This was evident from the personal style of rooms, which clearly reflected service users’ individual taste, interests and preferences. Service users, spoken to during the inspection, expressed a high level of satisfaction with their rooms and the home in general: ‘It’s first class here – better than a hotel’. Adequate internal, communal areas are provided and continue to meet the individual and collective needs of the service users, including a pleasant dining room and a light and spacious lounge. It was noted that the bathroom on the first floor is due to be redecorated and refurbished ‘in the near future’ and is currently out of action. This was discussed with a member of staff who confirmed that service users upstairs wishing to have a bath are escorted, using the passenger lift, down to the ground floor bathroom. Infection control procedures are in place and clearly adhered to and levels of cleanliness remain high throughout. Outside, the situation remains largely and disappointingly unchanged since the last inspection, with the uninspiring and uninviting concreted area at the rear of the building and the equally neglected and unappealing front patio area. Although the acting manager confirmed that wooden garden furniture is to be provided for the patio, as previously documented, with its uninterrupted sea views, some creative, professional input would enhance what could be and should be a real asset for the home. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. There are generally sufficient trained and competent staff on duty at all times to meet the assessed needs of the service users. Robust recruitment procedures ensure the safety and protection of service users, however the current provision of staff training, including induction training is unsatisfactory. EVIDENCE: Although mandatory training is provided in the home, there were notable gaps in the training matrix, on display in the office, and some concerns raised regarding procedures for staff induction. In files that were examined, there was insufficient evidence of what specific training was provided, by whom and on what date. As discussed with the acting manager, the content and structure of the current staff induction programme is inadequate and unsatisfactory and is required to be reviewed and significantly improved. There are currently three members of staff at Bybuckle Court with NVQ level 2 or above, which is below the required 50 of all care staff. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 20 Staff spoken to during the inspection remain clearly satisfied in their work, since the new acting manager was appointed and feel both valued and supported by her and the proprietor: ‘It’s a happier workforce and a happier home’. A rota is in place, showing which staff are on duty at any time and their designation. It is evident from discussions with staff, service users and relatives that there are sufficient staff on duty to meet the assessed needs of the service users. Recruitment policies and procedures are satisfactory, having been reviewed and improved, as required, since the previous inspection. Personal files relating to three recently appointed members of staff, examined during the inspection, were found to be generally well maintained, containing necessary information, including employment history, two references and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. Following discussion, the acting manager is to ensure that where POVA First checks have been completed, individual members of staff must only work under supervision until satisfactory CRB disclosures have been received. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service users benefit from stable and effective management, however there is a potential risk for service users from quality assurance systems that do not identify unsatisfactory health and safety practices and inadequate recording. EVIDENCE: The atmosphere in the home remains relaxed, friendly and welcoming. Staff, spoken to during the inspection felt valued and supported by the acting manager and confirmed her open and approachable style of leadership and clear and positive sense of direction. The acting manager is currently studying for the Registered Manager’s Award Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 22 (RMA). She already holds the NVQ level 3 in care and is aware of the need for additional units from the NVQ level 4 in care, to supplement the RMA. Quality assurance systems at the home have been improved since the previous inspection and now include statutory Regulation 26 visits by the proprietor. From reports already received by the CSCI it is evident that during this formal monthly monitoring visit, the proprietor speaks to service users and staff and inspects the premises, with regard to environmental standards (including the furniture and fittings and any necessary maintenance). Service user satisfaction questionnaires examined indicated a high level of satisfaction wit the home and the services provided: ‘I enjoy living here and I couldn’t think of anywhere better’. It was noted during the inspection that certain significant events, including a service user’s admission to hospital, had not bee reported to the CSCI, as required. There was evidence that the Notification form had not been reviewed since first being produced in September 2002. The acting manager confirmed that the majority of service users continue to maintain responsibility for their own finances. In cases where the home holds money on behalf of individual service users there was clear evidence that the money is held securely and all financial transactions are recorded. Since the last inspection, as required, formal staff supervision has been introduced and is now provided for all care staff every two months. However, as discussed with the acting manager, the recording format should be reviewed and amended and the supervision schedule is to be updated, to include recently appointed members of staff. In January of this year an inspection and audit of fire safety arrangements was carried out. Concerns raised by the fire officer at the time included several self closing devices on fire doors that required adjustment, the use of wooden door wedges to prop open doors and the need for regular checks of fire safety systems and equipment, including the emergency lighting and fire extinguishers. Despite subsequent recommendations by the Fire Safety Officer, following this audit, it was evident during my unannounced inspection that door wedges continue to be used throughout the home and fire safety checks are not being routinely carried out or recorded, as required. The most recent entry for testing of the emergency lighting was 27.04.2006. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 2 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 2 X 2 Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 14 (1) Requirement Timescale for action 31/07/06 2. OP18 13 (6) 3. OP20 23 (2) 4. 5. OP28 OP30 18 (1) 18 (1) 6. OP31 9 (2) It is required that new service users are only admitted to the home on the basis of a full needs assessment carried out by a person suitably qualified and competent to do so. It is required that service users be protected from abuse by appropriate training and robust policies and procedures which the staff are aware of and adhere to. (o) It is required that external grounds, which are suitable for and safe for use by service users, be provided and kept appropriately maintained. (Timescale of 31/10/05 not met) (c) It is required that 50 of care staff achieve NVQ level 2 in care. ( c) It is required that all staff receive a structured induction programme and training appropriate to the work they perform. It is required that the registered manager is qualified, competent and physically and mentally fit to manage the care home. DS0000021065.V292311.R01.S.doc 31/07/06 30/09/06 31/12/06 31/08/06 31/12/06 Bybuckle Court Version 5.1 Page 25 7. OP38 12 (1) 8. OP38 13 (4) (a) It is required that staff be aware 31/08/06 of and adhere to policies and procedures, ensuring the health, safety and welfare of service users and receive appropriate training, including fire safety. It is required that fire safety 31/07/06 systems and equipment are checked regularly and all parts of the home, to which service users have access, are free from hazards to their safety, including door wedges. 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. Refer to Standard OP7 OP36 Good Practice Recommendations It is recommended that details of an individuals wishes for arrangements after death are discussed and recorded in their care plan. It is recommended that the recording format for staff supervision be reviewed and amended and the supervision schedule be updated, to include recently appointed members of staff. Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 Page 26 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 Bybuckle Court DS0000021065.V292311.R01.S.doc Version 5.1 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!