Inspection on 01/11/05 for Self Unlimited North East

This inspection was carried out on 1st November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Self Unlimited North East 03/10/06

Self Unlimited North East 11/05/06

Self Unlimited North East 30/08/05

Self Unlimited North East 01/06/05

Self Unlimited North East 14/10/04

Self Unlimited North East 13/07/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Care Ponteland North Road Ponteland Newcastle Upon Tyne NE20 0BW Lead Inspector Elaine Charlton Announced Inspection 1st November 2005 09:00 Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 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 Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 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. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Care Ponteland Address North Road Ponteland Newcastle Upon Tyne NE20 0BW 01661-860333 01661 821830 careponteland@btconnect.com 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) CARE (Cottage and Rural Enterprises Ltd) Care Home 42 Category(ies) of Learning disability (42) registration, with number of places Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Six service users may also have a physical disability Two service users only are accommodated in Craster Cottage. Nine service users only are accommodated in Kielder Cottage, two of whom live in self-contained flats within the Cottage. Fifteen service users only are accommodated in Cheviot Cottage, one of whom lives in a self-contained flat within the Cottage. Sixteen service users only are accommodated in Burnside Cottage, two of whom live in self-contained flats within the Cottage. 30th August 2005 Date of last inspection Brief Description of the Service: CARE Ponteland is located on the outskirts of Ponteland village, in open countryside, close to local amenities which include shops, public houses, restaurants, health centre, churches and swimming pool. Accommodation comprises four purpose built residential units, 5 independent flats, workshops, central kitchen, dining room and administrative offices. A maximum of 42 younger adults with a learning disability live at CARE and access employment and educational opportunities both on and off site. Nursing and respite care are not provided. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was carried out on the 1 November 2005, at 9.10 am, by Elaine Charlton, and lasted for 9 hours. The focus of the inspection was requirements made at the last inspection on 30 August 2005 to ensure that they had been completed. As part of the assessment process service users care records and daily recordings by staff were checked in Cheviot, Burnside and Kielder cottages, cottage managers were present in the first two cottages and the deputy manager was on duty in Kielder. Communal areas in each of the cottages were seen and a random sample of medications were examined in Burnside cottage. Staff rotas and sample menus were forwarded to CSCI ahead of the inspection. Questionnaires were sent to all service users and 32 were returned. Some of these had been completed with the assistance of an independent advocate. Andrea Fox, Locality Manager, was present on site throughout the inspection. A large number of service users were spoken to around the site and the Locality Manager and Inspector had lunch with service users in the communal hall. What the service does well: What has improved since the last inspection? Co-operation with CSCI and other local authority agencies to the benefit of service users. Use of agency staff reduced to nil. Progress with the implementation of person centred planning identifying the needs of service users. New monitoring and reporting systems had been introduced giving staff clear direction and protecting the safety of service users. Premises repairs and refurbishments have been carried out promoting the health and welfare of service users and staff. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 6 The locality manager has been actively approaching local authority contracting departments to review care assessments to promote the health and welfare of service users. 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. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 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 Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 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): 2, 3 and 5. The new person centred plans and care plans promote the health, safety and welfare of service users. The detailed service user guide enables prospective service users and/or their families to know that CARE can meet their needs and aspirations. The presence of service agreements protects the welfare of service users. EVIDENCE: Person centred planning “taster” sessions took place during October. Facilitator training was organised for later in November. A person centred planning progress matrix and a progress-tracking table for each cottage have been introduced. Two person centred plans, in basic form, had been completed in each cottage. These were generally of a good standard but some documents had not been signed and dated, care plans did not always have the name of the service user on them and there had been some confusion about the completion of the care plan on death and dying. In Burnside cottage the death and dying care plans had been completed with care and were extremely sensitive and personal to the individual. Included in each service users file was a pictorial copy of the protection of vulnerable adults policy and residency agreement. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 9 There was evidence that service users had had care plans explained to them and they had had the opportunity to sign them. The new care plan format reflects how a service user wishes to be helped, by whom and when. These care plans are supported by a monthly evaluation sheet. Records showed increased involvement of social and health care professionals and Consultants are making regular visits to the CARE site. One Consultant is visiting every other month as part of a Downs and Dementia programme. Work is being done to access increased training opportunities for staff who are working closely with service users who have particular health and behavioural needs. Service users had had access to an independent advocate to help complete their questionnaire for the inspection. Thirty two out of 42 questionnaires were returned although two were blank. A consent form has been introduced recording a service users agreement to their photograph being held on file. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10. Person centred plans are signed by service users indicating their involvement and knowledge about the content, promoting their safety and welfare. Care plans record service users wishes and choices about how, by whom and when care is delivered to them promoting choice and independence. Risk assessments have improved promoting the health and welfare of service users. Policies and guidance on confidentiality and sharing information promote choice and privacy for service users. EVIDENCE: A new model of care planning has been introduced and includes a rigorous reviewing and updating process. A full copy of the documentation was forwarded to CSCI. This included the format for care plans, monthly evaluations, a tracking tool for reviews and a My Health Booklet for service users. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 11 Where original assessments are not available care managers are being approached to provide CARE with copies. A huge commitment by all the staff at CARE has been made to progress the updating of records. Three sessions of record keeping training had been delivered to staff and the Locality Manager is to follow this up on a cottage by cottage basis. Two report writing courses had been delivered and regular monitoring is taking place to ensure documents are properly completed. The range of risk assessments is being addressed as part of the new model of care planning and through staff training. CARE guidelines and the policy on confidentiality and disclosure of information have been recently reviewed. New copies were provided to CSCI. New and prospective service users will be shown copies of these as part of the assessment process. The guidelines detail the limits to sharing information without consent. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. The range of activities, education and employment opportunities and social events ensure that service users are part of the local community. Policies, procedures and guidance promote personal, family and sexual relationships whilst protecting the safety of service users. Meals times offer service users a good choice of healthy, hot, cold and vegetarian food. EVIDENCE: Day services on site give service users the chance to work in textiles, pottery, pattern making and sewing, design, tie dye, jewellery making, knitting, silk painting and printing. Self development groups include recycling, keep fit, music, bible study and the Speaking up Ponteland Group. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 13 Alternative therapeutic services include access to the library, reading, weaving, rhythmic instruments, golf driving range, lifestyle skills, numeracy, games, bowling, money handling, swimming and horse riding. A training suite for service users has been developed where they can have access to computers and their independence with kitchen appliances can be improved/assessed. A new member of staff has been appointed to improve service user access to employment. Two service users deliver newspapers in the local community supported by a member of staff. Building work commences in the Spring to provide a cafe, on-site, which will be staffed and run by service users. Work is being done to obtain contracts with shops and garden centres to sell the cards, pottery and gifts that service users are now producing. The goods produced are of a high quality. Service users said that activities on site were good. Clear policies and procedures support service users to plan holidays and decisions are recorded on a CARE Holiday Agreement form. Service users make good use of the communal hall and it was still decorated from their recent Halloween Party. Recent holidays/trips had included Disney Paris, Lightwater Valley, Tall ships, Centre Parcs and Eastbourne. Service users were seen clearly making choices about who they spent their time with and relationships were seen to be friendly with service users engaging in banter with each other. The new policy on relationships gives support to service users not to see someone, includes access to sex education programmes and highlights the need for risk assessments at all stages. Swindon University have been approached to provide training packs and training to support staff and service users making decisions about entering into close, personal, relationships. Daily routines are flexible within the limits of service users commitments to work and college. Service users were seen rising late and choosing how to spend their time. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 14 Service users have access to keys to their bedrooms but one service user asked for a front door key and this was referred to the Locality Manager. The Locality Manager has had recent discussions with the contract cleaners onsite and has drawn up a comprehensive programme covering staff responsibilities within the individual cottages. Service users are encouraged to take part in keeping their own bedrooms tidy and some also do their own laundry. All staff have been issued with guidance on the Safe Transportation of Food, and all food is probed before serving. Food temperatures are recorded in each cottage. Some entries were found to be missing on the day of the inspection. The main meal is served at lunch time and both hot and cold choices are available and include healthy and vegetarian options. Lunch in the main hall is a very social event and service users play pool, chat and socialise after their meal. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 15 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): 19 and 20. Records indicate that appropriate professional assistance is sought to support the physical and emotional health needs of service users. Medication policies, procedures and systems promote the health, safety and welfare of service users. EVIDENCE: The newly introduced My Health Record is comprehensive and will record all aspects of a service users health needs. Service users have access to GP’s and a variety of other health care professionals at the local health centre. As well as hospital based staff for more specific needs. A Consultant is visiting CARE on a fortnightly basis as some service users are taking part in a project on Downs and Dementia. Service users records clearly indicated that their health care needs were monitored and appropriate help sought as necessary. A new policy has been produced regarding the use of “covert medication”. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 16 A random medication check was carried out in Burnside cottage. Staff signature/initial lists were in place, all dispensed medications were signed for and all medication was kept in a secure manner. There were no controlled drugs currently in used but a system is in place to support secure storage and administration. At all times staff were seen to deal with medication administration issues in a sensitive and private way. Each service users person centred plan will include a care plan on ageing, death and dying recording the wishes of service users and/or the families in the event of a serious illness or death. Staff in Cheviot cottage had had difficulty with the completion of this care plan, but one seen in Burnside cottage was extremely personal and sensitive and clearly indicated the wishes of the service user involved. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 17 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 and 23. Complaint and protection of vulnerable adult procedures (POVA) are confidently used to protect the welfare and wellbeing of service users. EVIDENCE: Clear policies and procedures are in place supporting the acceptance, recording and investigation of a complaint or a disclosure. A standard concerns/complaints log has been introduced into all cottages. These will be reviewed by the locality manager who will send copies to the Assistant Director (Policy and Quality Assurance). In the short term complaints/concerns will be monitored on a weekly basis at the management meetings held on site. Monthly reports go to the Assistant Director who will also monitor person centred planning progress. Documentation is also in place to record compliments received. CARE’s whistle blowing policy was updated in January 2005, and includes details of outside agencies that anyone with a concern can also approach. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 18 The missing persons policy/procedure has also recently been reviewed. Reporting mechanisms on site and the quality of documentation was raised at a management meeting recently following CSCI receiving 2 incomplete Regulation 37 notifications. A new system has been introduced (standard across all cottages) by the Locality Manager to resolve the problem. A reportable occurrences monitor sheet has also been introduced and all cottages have been re-provided with the latest copy of the form and guidance to be completed for CSCI in the event of an incident taking place. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 19 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 and 30. The environment within the cottages is homely, comfortable and safe for service users. The cottages are clean and hygienic protecting the health and safety of service users and staff. EVIDENCE: The three requirements made at the last inspection about maintenance and repair issues had been met. Cheviot cottage lounge was much improved with the introduction of new furnishings and curtains and the involvement of service users who had been out purchasing pictures. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 20 The Fire Officer had copied his letter to CARE about a recent inspection to CSCI and indicated that the premises were suitable for the purposes of registration. A copy of CARE’s 5 year plan to update, modernise and reduce the numbers of service users living on site was provided to CSCI. The five requirements on hygiene issues made at the last inspection had all been met. Clear lines of responsibility between staff and contract cleaners have been identified and detailed in cleaning schedules. Compliance with the schedules is to be monitored on a weekly basis. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 21 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, 35 and 36. The fully staffed team will promote the health, welfare and safety of service users. The training review needs to be completed to ensure staff qualified and competent to meet the needs of service users. The frequency of supervision should be increased to ensure the health, safety and welfare of service users is promoted and monitored. EVIDENCE: An application has not been submitted for the post of Registered Manager at CARE. Four requirements made at the last inspection regarding staffing levels and training issues have been met. A training plan for 2006/07 is currently being produced. Thirty percent of staff currently hold a qualification at NVQ level 2 or above and 14 other staff are at various levels of completion of NVQ’s at levels 2, 3 and 4. Use of agency staff has been reduced to Nil. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 22 Kielder Cottage Staffing levels have been reviewed to ensure that 2 staff are on duty at times during the day. Cheviot Cottage Social Services have been contacted to review the needs of service users whose needs have changed. Negotiations are on-going regarding the funding of care packages and the provision of waking night staff. The Locality Manager and Regulation Inspector are to review staffing levels, by cottage, to establish a minimum level required to meet the needs of service users. CARE now has a full staff compliment and additional staff have been recruited to provide holiday and sickness cover. A Continuous Learning Pack has just been introduced and managers are to receive training to enable them to understand the system and use it effectively. New staff receive the Learning Disability Award Framework (LDAF) induction and foundation training. Training needs are assess as part of the personal development review for each member of staff. The Locality Manager is exploring access to new courses that support the needs of service users living at CARE. The level of supervision and support being offered does not currently meet the requirements of Standard 36. Cottage managers are being required to undertaken monthly supervision with staff initially and this will then reduce to 6 weekly. Each manager has been provided with a supervision folder setting out the purpose of, and system to be followed. Individual staff monitoring sheets have been introduced together with a signed contract. November has been identified as the month in which annual appraisals will be carried out. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 23 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, 39, 40, 42 and 43. Staff have access to a comprehensive range of policies, procedures and guidance to promote the health, safety and welfare of service users. The five year plan promotes the provision of quality accommodation and care to support service users to live as independently as possible. EVIDENCE: A new Locality Manager took up post on the 30 August 2005. CARE have appointed an Assistant Director of Policy and Quality Assurance. Nationally, there is a service user and staff consultation group. CARE Ponteland has established a family and friends group as part of the quality assurance and consultation process. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 24 Clear policy and guidance on the importance of quality assurance has been introduced. Locally a quality assurance co-ordinator has been appointed and has already carried out training with staff. Questionnaires for service users and stakeholders are already in place. The production of a regular newsletter is currently in consultation with the people who use CARE’s services, stakeholders and employees. A national date for production of annual quality assurance reports is to be agreed. A status report seen supporting the on-going process of policy review. This includes consultation with staff and service users before going to the Trustees. Since the appointment of the new Locality Manager there has been a clear demonstration of commitment to meet requirements, within agreed timescales, identified in CSCI inspection reports. Staff have easy access to up to date copies of policies, procedures and codes of practice. One health and safety requirement was made at the last inspection and this has been addressed. A fault reporting record has been issued to each cottage. This is a standard health and safety requirement in CARE establishments. An accident/incident/near miss document has also been issued to the cottages. This is also a standard health and safety requirement in CARE establishments. The Fire Officer had confirmed that following his recent inspection the premises at CARE were considered suitable for the purposes of registration. CSCI has access to a copy of the CARE 5 year plan for the Ponteland site. A Fund Raiser has been appointed to the CARE Ponteland site to support the implementation and funding of the 5 year plan. Service users living at Ponteland have been consulted about their future plans and wishes and approximately 20 have registered a wish to move off site to more independent living. Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 3 X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 2 X 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Care Ponteland Score X 2 3 X Standard No 37 38 39 40 41 42 43 Score 2 X 2 3 X 3 3 DS0000000598.V249399.R01.S.doc Version 5.0 Page 26 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 YA2YA6 Regulation 15 Requirement The introduction of person centred plans incorporating the new My Health Document must be completed. (Previous timescale of 30 March 2005 and 30 September 2005 partially met.) All care plans must be regularly reviewed and updated. (Requirement carried forward – timescale for action not yet reached.) Al records must be complete, dated and signed. The range of risk assessments must be increased with the implementation of person centred planning. (Previous timescale of 30 September 2005 partially met.) Food temperatures must be recorded and available within each cottage. Minimum staffing levels for each cottage must be established. Managers must receive training to promote the use of the DS0000000598.V249399.R01.S.doc Timescale for action 30/03/06 2 YA6 14/15 30/03/06 3 4 YA7 YA7 17 13(4) 30/12/05 30/01/06 5 6 7 YA17 YA32YA33 YA32 13(4) 18 18 30/11/05 30/03/06 30/03/06 Care Ponteland Version 5.0 Page 27 continuous learning pack. 50 of staff must be trained to NVQ level 2. CSCI must be provided with a copy of the 2006/07 training plan. The frequency of staff supervision must be increased. An application must be submitted to CSCI for the post of registered manager. Implementation of a quality assurance system must be progressed. (Previous timescale of 30 March 2005, 1 June 2005 and 30 August 2005, partially met.) 8 9 10 11 YA35 YA36 YA37 YA39 18 18(2) 8 35 30/01/06 30/12/05 30/12/05 30/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Care Ponteland DS0000000598.V249399.R01.S.doc Version 5.0 Page 29 - 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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