Inspection on 07/08/07 for Cascade Care Ltd

This inspection was carried out on 7th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Cascade Care Ltd 42 Ickburgh Road Lower Clapton London E5 8AD Lead Inspector Robert Sobotka Unannounced Inspection 7th August 2007 11:15 Cascade Care Ltd DS0000069411.V348065.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 Cascade Care Ltd DS0000069411.V348065.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. Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cascade Care Ltd Address 42 Ickburgh Road Lower Clapton London E5 8AD 0207 502 1797 0207 502 1797 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) Cascade Care Ltd Bandele Otuwehinmi Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Cascade Care Ltd DS0000069411.V348065.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: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 5 N/A Date of last inspection Brief Description of the Service: Cascade Care Ltd is a residential care home, which offers care, support and accommodation for a maximum of five male residents within a community setting. The home provides rehabilitation services for men with a history of mental health issues and subject to community sections as a discharged person on Sections of the Mental Health Act 1983 i.e. 37/41 or the Mental Health (Patients in the Community) Act 1995 i.e. supervised discharge. The home is situated in a residential area of Lower Clapton and is within 5 minutes walking distance of Clapton British Railway station. Access to local busses 38, 253, 254, S3, D6, 48, 55 and 56 are approximately 5 minutes walk from the home with routes covering the City, London Bridge, Aldgate and Euston. The property is a large Victorian terraced house, which consists of five large individual bedrooms (3 en suite and 2 with a shared bathroom), a comfortable television lounge with a Cable TV etc, separate laundry area, bathroom and WC, separate WC, large dining room, fully equipped communal kitchen. There is also a garden at the rear of the building. The premises are not wheelchair accessible. Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day and was unannounced. As part of this visit, the inspector spoke to all three people who were using the service, one member of staff (newly promoted deputy manager) and the registered manager. He viewed various documents and carried out a tour of the premises. Prior to this inspection the home was asked to complete the Annual Quality Assurance Assessment. Some of the information provided in the assessment has been incorporated into this inspection report. This was the first inspection of the home since it opened in March 2007. The purpose of this visit was to assess the home’s compliance with the National Minimum Standards for Adults (18-65) and The Care Homes Regulations 2001. The inspector would like to than all service users and staff who contributed to this inspection. What the service does well: What has improved since the last inspection? What they could do better: Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 6 The following 7 statutory requirements were issued during this inspection visit: - The registered manager must ensure that each service user has an up-todate care plan, which covers all aspects of personal and social support and healthcare needs as set out in Standard 2 of the National Minimum Standards for Adults, in order to demonstrate how each person’s assessed needs are going to be met by the home. - The registered manager must ensure that each care plan contains a photograph of the service user, in order to comply with the Care Homes Regulations 2001. - The registered manager must ensure that all risk assessments (and other documents) are dated when implemented; in order to demonstrate that risk assessments and other documents are being reviewed on a regular basis and are valid. - The registered manager must ensure that he keeps records of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service users. - The registered manager must ensure that service user’s weight is monitored and recorded as indicated within care plans, in order to demonstrate that the healthcare needs of a service user are met. - The registered manager must ensure that the garden is tidied up to ensure the health and safety. - The registered manager must obtain a relevant qualification in management. 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. Cascade Care Ltd DS0000069411.V348065.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 Cascade Care Ltd DS0000069411.V348065.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, 3, 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with sufficient information about the home to make an informed choice as to whether to move in. Good assessments systems were in place. Service users are able to test-drive the home prior to moving in. Improvements were required to the service users’ care plans in order to demonstrate that each person’s assessed needs were being met. EVIDENCE: The home had an up-to-date statement of purpose and the service user’s guide in place. Both documents include useful information about the home and covers topics, such as Mission Statement, Introduction to the home and local area, Description of the home, Referral/Admission criteria (including emergency admissions, Range of Needs met by the home, Service User’s Care Plans, Core Principles of care, Resident’s Rights, Facilities and Services, Quality Policy, Social Activities, Hobbies and Leisure Interests and all other information as required by the Care Homes Regulations. There have been three new admissions to the home since it opened. The inspector viewed care plan files of all service users. Documentation viewed demonstrated that a thorough assessment was carried out in respect of each person. There was also evidence that appropriate and relevant information had Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 9 been obtained from the placing authority. Healthcare professionals, such as psychiatrists, community psychiatric nurses etc, were also involved prior to admission of each person to the home. The inspector was unable to fully assess whether the home was appropriately meeting the needs of each service user, as at the time of this inspection visit further work was required to ensure that each person had an up-to-date care plan, which fully outlined each person’s assessed needs. In order to meet this standard fully, the registered manager must ensure that each service user has an up-to-date care plan, which outlines treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet the current and changing needs and aspirations and achieve goals. (Please refer to Standard 6 for further details.) Each service user is able to “test drive” the home prior to moving in there on a full-time basis. The inspector spoke to the service users all of whom confirmed that they visited the home on several occasions prior to moving there. Record to that effect was also seen on his file. In addition the registered manager produced detailed reports following each visit to the home, copies of which were available for inspection. Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are required to the home’s care planning systems. Service users were encouraged to take part in making decisions relating to the care they needed. Confidentiality was being maintained. EVIDENCE: As part of this visit the inspector checked care plans of all three service users accommodated in the home. Each person who used the service had a care plan in place, however at the time of this visit individual care plans concentrated on each service users’ mental health needs, whilst other areas which would describe how each person’s physical, religious and cultural needs would be met was not incorporated into these document. At the time of this inspection one of the service users had a physical disability and although there was evidence in various documents that this was proving to be a challenge for some staff, as they did not appear to be aware of the service users abilities. The care plan for that service user did not include any information would indicate as to how the service user was being supported with every day tasks and what kind of support was required in relation to his physical disability. This required Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 11 improvement. The inspector raised this issue with the registered manager who stated that care plans were currently being developed with involvement of service users. The registered manager must ensure that each service user has an up to date care plan, which covers all aspects of personal and social support and healthcare needs as set out in Standard 2 of the National Minimum Standards for Adults, in order to demonstrate how each person’s assessed needs are going to be met by the home. In addition, none of the care plans contained a photograph of a service user. This requires improvement. Service users living in the home confirmed that that they were able to make informed choices and decisions and that both members of staff and the registered manager respected their views. Those who used the service were free to make choices around their daily living and were consulted about how the home should be run. Their views are obtained during individual keyworking sessions and residents meetings. This was also confirmed by the people who use the service during their discussions with the inspector. Each file viewed contained appropriate risk assessments. The inspector was unable to assess whether risk assessments were being reviewed, as this is a new service and all risk assessments were not due for review at the time of this inspection visit. The inspector noted that one of the service users’ risk assessments was signed but not dated by the author. This required improvement. Confidentiality was being maintained. All confidential information was kept in the office, which was kept locked when not in use. Staff working in the home shared information about the service users with the inspector on a need-toknow basis. Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who lived in the home are encouraged and supported to become part of the local community and develop and maintain friendships and family links. Service users enjoyed food in their home. Record of food offered to people who used the service required improvement. EVIDENCE: As this is a recently opened home and service users have lived in the home were only just settling in there, the inspector was unable to asses the standard fully. It was noted however that there was evidence in each service users’ file, that discussions have been taking place between service user and staff during keyworking sessions and at other times about taking up leisure activities in the local area. Those who spoke with the inspector said that they were looking at leisure activities in the local area, which would suit their needs. This also included further education classes. Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 13 The home organises annual holidays for the people who use the service, which are paid by Cascade Care Ltd. The registered manager stated that both him and staff working in the home encourage and support service user to develop friendships and family links. Care plans viewed showed that service users maintain contact with their families where appropriate. One of the people who used the service told the inspector that visitors are allowed in the home during daytime and staff respect service users’ right to develop and maintain friendships. Any restrictions in relation to visiting hours and visiting arrangements are included in the home’s Statement of Purpose and Resident’s Handbook. People who used the service told the inspector that they enjoyed food served in the home. There were sufficient food supplies, which were appropriately stored. Staff support service users with preparation of a lunchtime meal and service users are responsible for preparation of breakfast and supper. The inspector shared cooked lunch with the service users, which was nutritious, tasty and attractively presented. Record of food offered to each service user was being maintained, however it required improvement, as at the time of this inspection visit it did not fully demonstrate as to what food as been offered to the people who used the service. The registered manager must ensure that he keeps records of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service users. Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are required to demonstrate that the healthcare needs of the service users accommodated in the home were being met. Appropriate medication systems were in place. EVIDENCE: At the time of this inspection visit, there were three service users accommodated in the home. As previously mentioned all three care plans did not include sufficient information in relation to each service users’ physical needs (including personal care). In the Annual Quality Assessment review the registered manager stated that one service user required support from staff with some tasks as laundry, vacuuming and mopping due to his physical disability coupled with his mental health issues. This was not reflected in the individual’s care plans and as a result there appeared to be inconsistencies as to what support was offered to the service user. It was noted that the home has involved an Occupational Therapist to provide adaptations in the home for the service user with a physical disability. Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 15 Two of the current service users have been registered with a General Professional and the home was in the process of registering the most recently admitted service user with a local GP. Service users were supported and encouraged to utilise community health resources. During the review of one of the service user’s files the inspector noted that staff were not maintaining a record of weight of the service user, even though there were medical issues related to the person’s weight and it has been identified that his weight should be monitored. The registered manager must ensure that service user’s weight is monitored and recorded as indicated within care plans, in order to demonstrate that the healthcare needs of a service user are met. Medication systems were checked and were found correct. At the time of this inspection visit, one of the service users was administering his medication. Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had appropriate complaints system in place. Those living in the home were protected from abuse, neglect and self-harm. EVIDENCE: There have been no complaints made to the home since the home opened in March 2007. Appropriate complaints policy was in place. Those who lived in the home were given opportunities to raise their concerns about the way the home is run, during resident’s meetings and their keyworking sessions. One of the service users who spoke with the inspector said that he would feel comfortable raising any concerns with the registered manager or a member of staff. At the time of this inspection visit all of the service users were managing their finances. The registered manager stated that support and guidance was offered to those who may require help in managing their finances. The inspector viewed the home’s accidents and incidents records. There have been two incidents recorded, none of which were considered as “reportable” to the Commission under the Regulation 37. Members of staff have attended Adult Protection Training. Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28, 30. 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 a well-maintained, homely and clean environment, however the rear garden required attention. EVIDENCE: The property is a large Victorian terraced house, which consists of five large individual bedrooms (three en suite and two with a shared bathroom), a comfortable television lounge with Cable TV etc, separate laundry area, bathroom and WC, separate WC, large dining room, fully equipped communal kitchen. There is also a garden at the rear of the building. The premises are not wheelchair accessible. As part of this visit, the inspector carried out a tour of the premises. He viewed all communal areas, as well as one of the occupied bedrooms and one vacant bedroom. As the home has recently been opened, the premises were well-maintained. Service users who spoke to the inspector confirmed that they were given Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 18 choice as to which bedroom they preferred to occupy. They also said that they liked the environment and were happy with communal and private facilities. There was adequate communal space in the home. There is a garden at the back of the home, which at the time of this inspection was overgrown and required attention. The premises were found to be clean and hygienic at the time of this inspection visit. Appropriate laundry facilities were in place. Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are supported by staff who are committed to providing good quality of care and appropriately trained. There were adequate staffing levels in place. Appropriate recruitment practices were in place. EVIDENCE: The inspector viewed duty rosters, which showed that there were sufficient numbers of staff on duty. There are two members on each shift, including nights. Night staff remain awake throughout the night. Staff spoken to stated that they felt that staffing levels were sufficient. The majority of staff either have obtained the NVQ qualification or were in the process of obtaining one. As part of this visit, the inspector checked staff personnel files of 5 members of staff, which were chosen at random. Records viewed demonstrated that staff have been appropriately recruited and all checks were undertaken prior to members of staff commencing employment with vulnerable adults. Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 20 The registered manager stated that last year (around May 2005), the organisation carried out an assessment of staff training needs and refresher training courses have been put in place. Most of the statutory training has been completed, except for the newly employed staff, however they have been booked to attend their training. Regular team meetings were taking place, minutes from which were available for inspection. Records of staff supervision were not checked on this occasion, but will be checked during the next inspection visit. Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by a competent manager, however he must obtain his management qualification within set timescale. Appropriate quality assurance systems were in place. Health and safety checks were also in place. EVIDENCE: The home has a new registered manager in place, who has been approved by the Commission as fit to manage a residential home. He is a qualified Social Worker and has previously worked in another home run by Cascade Care Ltd, also as the registered manager. In order to meet the standard 37 fully, the registered manager must obtain a relevant qualification in management. During the course of the visit, the inspector received positive comments from both service users and staff about the registered manager’s performance and Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 22 his capabilities. People who used the service felt that the manager was fair, approachable and friendly. The new Responsible Individual has been carrying out “the Regulation 26 visits”, reports from which were being forwarded to the Commission. Appropriate health and safety checks were in place. The home was adequately insured for its purpose. Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 23 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 3 2 3 3 2 4 3 5 x 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 3 25 X 26 X 27 x 28 2 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 x 2 x 3 x x 3 x Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 YA3 YA18 Regulation 15(1) Requirement Timescale for action 01/10/07 2. YA6 17(1)(a) Sch 3 3. YA9 17(3)(a) 4. YA17 17(2) Sch 4.13 The registered manager must ensure that each service user has an up to date care plan, which covers all aspects of personal and social support and healthcare needs as set out in Standard 2 of the National Minimum Standards for Adults, in order to demonstrate how each person’s assessed needs are going to be met by the home. The registered manager must 01/10/07 ensure that each care plan contains a photograph of the service user, in order to comply with the Care Homes Regulations 2001. The registered manager must 01/10/07 ensure that all risk assessments (and other documents) are dated when implemented; in order to demonstrate that risk assessments and other documents are being reviewed on a regular basis and are valid. The registered manager must 01/10/07 ensure that he keeps records of the food provided for service users in sufficient detail to DS0000069411.V348065.R01.S.doc Version 5.2 Cascade Care Ltd Page 25 5. YA19 12(1)(a) 6. YA28 23(2)(o) 7. YA37 9(2)(b)(i) enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service users. The registered manager must ensure that service user’s weight is monitored and recorded as indicated within care plans, in order to demonstrate that the healthcare needs of a service user are met. The registered manager must ensure that the garden is tidied up to ensure the health and safety. The registered manager must obtain a relevant qualification in management. 01/10/07 15/10/07 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cascade Care Ltd DS0000069411.V348065.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Cascade Care Ltd DS0000069411.V348065.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!