Inspection on 08/05/07 for Cavendish House

This inspection was carried out on 8th May 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cavendish House 24/06/05

Cavendish House 01/11/04

Cavendish House 17/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Cavendish House Cavendish House 4 Saxbys Lane Lingfield Surrey RH7 6DN Lead Inspector Lisa Johnson Unannounced Inspection 8th May 2007 09:30 Cavendish House DS0000013585.V339073.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 Cavendish House DS0000013585.V339073.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. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cavendish House Address Cavendish House 4 Saxbys Lane Lingfield Surrey RH7 6DN 01342 833297 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) d.elcocktinternet.com Monica Cantwell Trust Mr Gerald Michael Loney Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18-65 YEARS 24th June 2005 Date of last inspection Brief Description of the Service: Cavendish House is a large terraced house situated in the village of Lingfield approximately eight miles from Horley in Surrey. It provides care for up to five younger adults with a learning disability. All bedrooms are single and most are found on the first floor which is accessed by a flight of stairs. One bedroom is located on the ground floor. The home provides communal areas with two lounges, a dining room and a family style kitchen. There is a good size garden to the rear of the property, that is fenced and secure. There is only on-road parking availble in front of the house. The fees range from £692.31- £929.02 Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The visit was unannounced and took place over seven and half hours commencing at nine thirty am and finishing at Five o’clock. The visit was carried out by Mrs. L Johnson Regulation Inspector. Mr. G Loney Registered Manager represented the establishment. The inspector spoke to three people who live in the service to gain their views on the care provided. Five comment cards were received from people using the service and two relative comment cards were received. Comments were also received from two health care professionals and these comments are reflected in this report. A full tour of the premises took place. Information was examined which was provided by the manager with the pre- inspection questionnaire. Staff training records, care plans and policies and procedures were sampled. The inspector would like to thank the people using the service and staff for their time, assistance and hospitality during this inspection. What the service does well: The service provides a homely and friendly atmosphere. Positive relationships were observed between people using the service and the manager who had a good knowledge of individuals needs. People living in the home are supported to make choices about their lives. One individual said, “we have weekly meetings where we can discuss things”. It was clear that people living in the home are supported to access a range of activities and take part in the local community. One individual said, “I do a paper round and another person said, “ I have a busy week and I go to college”. During the week people have the opportunity to assist with household tasks and one individual said, “I do my washing” and another person said, “I like to cook cottage pie”. Two people said they regularly attend church, which meets their religious preferences. Other activities included using the local library, going shopping, visiting the theatre and cinema swimming and attendance at a drama group. A relative commented, “we feel that the house provides our relative with both learning and social opportunities enabling him to live a fulfilled life”. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: It was recommended that the home introduce a pre- admission assessment to be completed for future prospective people moving in to the service. Improvement is needed to ensure that the service develop their own individual care plans in consultation with people using the service which identify their individual needs, objectives and goals. Plans should also include detail each individuals preferences and the personal support they require. Risk assessments must be expanded to include all identified risks and hazards and recorded in the care plan. It is recommended that people using the service are provided with a key to their bedroom and where an individual chooses not to have key this should be recorded in their individual plan. The medication arrangement in the home-required improvement in relation to some recording practices and a risk assessment was required for one person. The home must acquire the up to date version of the local authority multiagency safeguarding adults from abuse procedure. Improvement is needed to ensure that staff receive updated training in safeguarding adults from abuse and other mandatory training including food hygiene and infection control. Quality assurance surveys must be conducted to gain feedback from people using the service, their representatives and other stakeholders to ensure that the home is run in their best interests. Written reports must be obtained for monthly quality visits The home must complete a risk assessment in respect of the uncovered radiators throughout the home ensuring the health, safety and welfare of people using the service. The home must ensure that the water temperature is checked for compliance with legionella. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 8 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 Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 9 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): 2 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The needs of prospective service users are assessed prior to admission to the home. EVIDENCE: There have been no admissions to the home since the previous visit. The home has clear admissions policy in place. Information was examined for three people who live in the service. Two individuals have lived in the home for a number of years The home was in possession of a community care assessment and it was evident that information had been obtained from a variety of sources. The manager stated that he visits prospective individuals who also have the opportunity to visit the home ensuring that the new person would be compatible with the current group of people living in the home. One individual commented, “I had a visit here and slept over”. The home does not have their own pre- admission form to use; therefore it was recommended that a pre- admission form be introduced to be completed for all future referrals. Cavendish House DS0000013585.V339073.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 & 9 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Further improvement is needed to ensure that people using the service are provided with an individual care plan, which records their individual needs and goals. Service users are supported to make decisions about their lives with assistance. Further improvement is needed to ensure that people using the service are supported to take risks as part of an independent lifestyle. . EVIDENCE: During this visit care plans were sampled for three people living in the service. There was evidence that annual reviews are conducted in consultation with individuals, their relatives and health care professionals and a care plan was in place, although the service has not developed their own individual care plans to identify the current needs and goals of each person. The manager stated that weekly meetings are held to monitor the progress of each person and a record book was maintained. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 11 Each person has a monthly one to one meeting with his or her key worker but this is takes place on an informal basis. Therefore it is required that the home develop individual care plans in consultation with people using the service which reflect their current and changing needs, objectives and goals and how these are to be achieved. Service users are consulted and supported to make decisions about their lives with assistance where required. This was confirmed by one individual who said that the home holds weekly community meetings and they are able to raise any issues. People living in the home are consulted and involved in menu planning. Further improvement needs to make with risk plans which should be incorporated within the care plans and where risks were identified plans must be put in place on how to minimise these risks. Discussion took place with the manager about risk plans for example for one person who was making tea in the kitchen. Cavendish House DS0000013585.V339073.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 People using the service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. Service users are provided with a range of appropriate activities and engage in a range of leisure activities. Service users are supported to take part in the local community and the rights and responsibilities of service users are respected. The home is able to demonstrate that service users are provided with a well-balanced and nutritious diet. EVIDENCE: The home provides a wide range of activities for service users to attend. During the inspection service users were busy leaving to attend day services. Information provided by the manager described in detail the range of activities. One person told the inspector said that they would be participating cookery and another individual said that he would be doing gardening while at day services. One person living in the house said,” I do a paper round” and another individual said she attends college. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 13 It was evident that people living in the service are actively engaged in the local community including helping with Meals on Wheels and assisting in the trusts own charity shop. During the week people have the opportunity to assist with household tasks and one individual said, “I do my washing” and two people said they regularly attend church, which meets their religious preferences. A comment received from a relative stated, “ I appreciate the Christian ethos and that religious practice is encouraged and made possible for resident”. People using the service have access to a range of activities including using the local library, going shopping, theatre and cinema trips, swimming and attendance at a drama group. Another comment received stated”, “we feel that the house provides our relative with both learning and social opportunities enabling him to live a fulfilled life”. One person spoken with said that she is the only female residing in the home and would like the opportunity to go out more for clothes shopping which was bought to the attention of the manager. People living in the home are supported to go on annual holidays. One person said he had stayed in a caravan and another Individual said, “I went to Butlins”. People living in the home have good family support and individuals spoken with during this visit spoke about their visits when they visit their families. Comments received from relatives included, “The home provides a friendly welcoming service”. Good relationships were observed between the people using the service and friendly and positive interaction was taking place. People living in the home had unrestricted access in the home and one individual was observed to making cups of tea in the kitchen. Another person spoken with said that that they like a lay in at weekends and that staff respect this. The home has an equal opportunities policy in place, which outlines peoples rights to make choices and have their privacy respected. People living in the service are on the electoral role and had the opportunity to vote in the recent local elections. People living in the service also have the opportunity to participate in menu planning. A comment from a relative stated, “the home provides choices where this is appropriate”. It was observed that people do not have keys for their bedroom doors and one individual told the inspector that they would like a key for their room to keep their possessions safe. Therefore it is recommended that this matter be attended to ensuring the rights and responsibilities of people living in the service. Where individuals choose not to have their own key this should be recorded in their individual care plan. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 14 Copies of the homes menus were provided by the manager with the preinspection questionnaire. As all of the people living in the home were all out of the home at lunchtime the meal could not be observed. However menus were observed to be varied and well balanced. People living in the service said that they enjoyed their meals and were able to choose meals of their preference. One Individual said she cooks occasionally and enjoys preparing “cottage pie”. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the service receive support in the way that they prefer. Service users physical and health needs are met. Further improvement is needed in ensuring that people living in the home are protected by the homes medication administration procedures. EVIDENCE: Each person is supported by a key worker who meets with each individual monthly on a one to one basis. There is stable staff team in place who have knowledge of the needs of individuals. Information provided indicated that a range of health care professionals including a local General Practitioner, chiropody, dentist, optician and community nurses, support people living in the service. The inspector was informed that where people consult with health care professionals this is recorded in the daily records. A comment received from a health care professional stated, “The home has always been willing to work with me”. Another comment received indicated that the staff supported their relative well with a health issue. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 16 It is recommended that peoples individual preferences are recorded in the individual care plan ensuring that individuals receive the support in the way they prefer and require. The homes medication policies and practices were examined. The home has implemented their own medication recording sheets, which are transcribed by staff, although the author who had transcribed the prescription had not signed these. An immediate requirement was made that this matter must be attended to and was responded to by the manager during this visit. It was also recommended that where possible two members of staff should witness and check this medication. One individual is supported by staff to administer their medication, which is retained, by staff and the person is provided with support to administer these items from the container. A requirement made that a risk assessment be completed ensuring the health, safety and welfare of individuals. Further recommendations were made that a list is maintained of all staff that are trained and authorised to administer medication and kept with the medication administration records. The homes medication administration policy needs reviewing and updating to reflect current good practice Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that the views of service users are listened to and acted upon. Improvement is needed to ensure that people living in the service are protected from abuse. EVIDENCE: The home has a complaints procedure in place and there have been no complaints received by the service since the previous visit. Five comment cards received from people living in the service conclude that service users feel that they are treated well and they know who to speak to if they were unhappy or needed to raise a concern and that staff listen and act on what they say. One individual commented, “”the staff are caring” and another individual said, “I like living here”. Two comment cards received from relatives indicated that they were aware of the homes complaint procedure and were satisfied with the care provided in the home and were kept informed of important matters in respect of their relative. There have been no referrals made under the local authority multi- agency safeguarding adult’s procedures. This procedure was available in the home but the updated version must be obtained. The service also as a local safeguarding and whistle blowing policy. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 18 The manager stated that staff had received appropriate training. Three staff training records were examined which evidence of only one member of staff attending the training which was some time ago and records were not available for the other two members of staff to confirm their attendance. Therefore a requirement was made that all staff must receive updated training to ensure that people living in the home are protected from abuse. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. One matter needs attention to ensure that people living in the home have a well-maintained, comfortable, homely and clean environment. EVIDENCE: The service is close to Lingfield town centre and local amenities and provides a homely atmosphere. There are plans to replace some of the flooring and some redecoration is needed. The inspector was informed that the trustees have secured purchase of a property adjacent to the home, which will result in refurbishment to the home. The home is spacious and has a separate dining and living room. A carpet in the corridor requires attention, which was coming away from the runner, and this matter was bought to the attention of the manager to action, as this is safety hazard. Bedrooms viewed were comfortable and reflected individuals preferences and interests with a range of personal possessions on display. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 20 There is a large accessible and well-maintained garden to the rear of the house. The home was cleaned to a good standard and was hygienic. Separate laundry facilities were available. However staff training schedules indicated that staff should receive training in infection control. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 36 People using the service experience adequate outcomes in this area This judgement has been made using available evidence including a visit to this service. Competent and qualified staff supports people living in the home and they are protected by the homes recruitment policy and practices. Improvement is needed to ensure that staff receive appropriate training ensuring that the needs of people living in the service are fully met. EVIDENCE: Information on the staffing arrangements in the home was provided with the pre-inspection questionnaire. During this visit two members of staff were on duty until nine am. On this particular day all of the people in the home attend a day service provision and are accompanied by the manager. Two staff are provided in the evening and at night there is sleep-in member of staff. The service benefits from a stable staffing team. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 22 Pre-inspection information stated that thirty percent of care staff have obtained National Vocational Qualifications (level 2) or above. Training records were sampled for three members of staff there was evidence that staff have attended some training and development appropriate to support the current group of people living in the home including epilepsy, learning disability and behaviour, however improvement is required with staff receiving mandatory training. Evidence was seen that staff have completed fire awareness training, one person had received safeguarding adults from abuse training but this had not been updated recently. Another person had attended training in first aid. There was no evidence observed that staff had received food hygiene or infection control training. Therefore it was required that the manager ensures that all staff have completed and updated training in these matters and ensure that records are kept up to date. As the home has not recruited new staff for a long period of time induction training was not looked at during this visit however the manager was advised to refer to good practice guidance should new staff be recruited to the home. The personal files were examined for three members of staff and contained, application forms, contracts, identification, two references and police checks with the issue date and number recorded. A copy of the General Social Care Code of Conduct was seen in the staff office. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service Further improvement is needed to ensure that the service is run in the best interest of people living in the service. The health and safety of service users is mainly protected with two matters needing attention. EVIDENCE: The registered manager is a qualified social worker and holds a B. Phil in educational studies and has a number of years working in social care and in a management capacity. The home holds regular staff meetings. One comment received stated, “the staff team and management are approachable and wish to provide a quality service which on the whole they appear to be doing”. The home consults with service users and relatives on a regular basis with records maintained of meetings, although the home has not carried out quality Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 24 assurance surveys for people using the service and their representatives. A requirement was made that surveys are conducted to ensure that the home is run in the best interest of people using the service The manager stated that the trustees visit on a regular basis, however it was required that written records are maintained of quality visits with written reports being maintained in the home. The fire records were examined and it was evident that staff have received training in fire awareness, alarm checks are tested weekly and an up to date fire drill has been conducted. Information received indicates that that regular servicing and maintenance of equipment is completed. However a record was not available confirming the compliance with legionnaires and it is required that this matter is completed. During a tour of the home it was noted that radiator covers had not be supplied throughout the home and a requirement was made that a risk assessment is completed ensuring the health, wellbeing and safety of people living in the home. Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 2 X X 2 X Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15(1)(2) (a)(b)(c) Requirement Individual care plans must be developed with each person living in the home to reflect each individual’s current and changing needs and personal goals. Risk assessments must be expanded to include all identified risks and hazards and recorded in the individual care plan A risk assessment must be completed for one individual who is assisted to administer their own medication ensuring their health, safety and wellbeing a) All staff must receive up to date training in safeguarding adults to ensure they are protected from abuse. b) The updated copy of the local authority multiagency safeguarding adults from abuse policy must be obtained. All staff must receive up to date mandatory training ensuring the health, safety and wellbeing of people using the service a) Quality assurance surveys must be conducted to gain DS0000013585.V339073.R01.S.doc Timescale for action 22/06/07 2 YA9 13(2) 13(4)(B) (C) 13(2) 13(4)(b) (C) 13(6) 22/06/07 3 YA20 21/05/07 4 YA23 19/09/07 5 YA35 18 (C) (i)(ii) 24(3) 26 19/09/07 6 YA39 19/08/07 Cavendish House Version 5.2 Page 27 feedback from people using the service and their representatives ensuring that the home is run in their best interests b) Written reports must be maintained of monthly quality visits. A risk assessment must be completed for the uncovered radiator covers in the home ensuring the health, welfare and safety of people using the service. The water must be checked to ensure compliance with legionella 7 YA42 13(4)(C) 21/05/07 8 YA42 13(2)(4) (c) 08/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard YA2 YA18 YA16 Good Practice Recommendations It is recommended that the manager develop a preadmission document to be completed prior to any individual moving in to the service. The personal preferences and support needs of individuals must be recorded in their individual plan. It is recommended that the manager provides people living in the home with a key for their bedroom and where individuals choose not to use a key this should be documented in their individual care plan. It is recommended that the home reviews and updates its mediation administration procedure to reflect current good practice. The registered manager should consider supplying a list of all staff who are authorised to administer medication with the medication administration records. 4 5 YA20 YA20 Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Cavendish House DS0000013585.V339073.R01.S.doc Version 5.2 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. 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