Inspection on 23/04/07 for Cleeve Villas

This inspection was carried out on 23rd April 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 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cleeve Villas 11/09/06

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOME ADULTS 18-65 Cleeve Villas 69/70/71 Wilson Street Derby Derbyshire DE1 1PL Lead Inspector Nancy Bradley Key Unannounced Inspection 23rd April 2007 10:00 Cleeve Villas DS0000061805.V332817.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 Cleeve Villas DS0000061805.V332817.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. Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleeve Villas Address 69/70/71 Wilson Street Derby Derbyshire DE1 1PL 01332 383187 01283 734984 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) Cleeve Villas Care Services Limited Mr Stephen Maurice Kent Care Home 14 Category(ies) of Learning disability (14), Mental disorder, registration, with number excluding learning disability or dementia (14) of places Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Cleeve Villas Care Services Limited is registered to provide nursing, personal care and accommodation for service users whose primary care needs fall within the following categories: Learning disability (LD) Mental disorder (MD). Admission of one named person over 65 years of age under the category mental disorder (MD). Refers to application received on 26.1.07). The maximum number of persons to be accommodated at Cleeve Villas is 14. 2. 3. Date of last inspection Brief Description of the Service: Cleeve Villas is a late Victorian building situated within a few minutes walk of the Derby city centre. The home has fourteen single en-suite bedrooms, including one specifically for the needs of wheelchair users. The communal areas include the dining area, lounge, quiet room, kitchen, bathroom and toilets. The home provides care for service users who have mental health needs and a learning disability and are 18 years of age and over. The home has a qualified psychiatric nurse on duty 24 hours a day, along with trained care assistants. Information on fees was not available. The Registered Manager stated fees are dependant on need and arranged by the Director’s of the Company. Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection was unannounced and took place over five hours. The inspector spoke with the Registered Manager, care staff and made a tour of the building. Records were examined relating to the two service users and the general operation of the home. Additionally, time was spent in preparation for the visit, looking at the pre inspection questionnaire. Currently the home is caring for twelve service users No family or relatives were present during this visit. At the time of the inspection ten service users maintain their own financial affairs and two service users are subject to Power of Attorney and Guardianship. From the ten-service user questionnaires sent out seven completed ones were returned and comments from them stated 1. They were quite settled at the home. 2. They were asked if they wanted to move into the home. 3. They are able to make decisions about what they do each day. 4. They felt that the carers listened to them and cared for them well. Only one service user was willing to speak with the inspector. What the service does well: What has improved since the last inspection? At the last inspection the home was only a third full, and is now operating at full occupancy numbers. Since the last inspection the home has submitted a variation to its registration. The home has been able to recruitment new staff and they all are either qualified or working to wards qualification. Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 6 The home is continuing to manage its transition form a private hospital to a care home. 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. The summary of this inspection report can be made available in other formats on request. Cleeve Villas DS0000061805.V332817.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 Cleeve Villas DS0000061805.V332817.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): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that service users needs are fully assessed and met prior to admission this ensures that all potential service users holistic needs are appropriately met. EVIDENCE: The individual records of two service users were checked. Service users admitted to the home have their needs assessed through social work assessment, the care management system, or psychiatric assessment. This highlights any additional requirements, and the need for additional staffing. The home also undertakes their own individual comprehensive needs assessment. The assessments then form part of the service user plan compiled by the Registered Manager This was in accordance with the Cleve Villas care assessment procedure to provide a person-centred record of their individual needs. The assessment also recorded significant events in the service users life and reflects the involvement of the service user and significant others. There was evidence on file that the needs assessments are reviewed by the referring agency. Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a care planning and review system in place, which ensures that service users individual needs are met EVIDENCE: During the visit care plans of two service users were examined. The care plans have been compiled by the Registered Manager on each service user and evidence was seen of care plans being reviewed on a regular basis. Care plans included services users’ individual lifestyle preferences and choices; the interventions prescribed by outside healthcare professionals were appropriate. Daily records are also maintained on each service user. The Registered Manager stated that service users knew about their care plans; they were personalised and reflected the individual needs of the service user. However nether the service users or their representatives had signed them. The home offers a structured multi disciplinary care planning and rehabilitation approach for service users. Throughout the visit care staff were observed encouraging service users to make decisions, which affect their daily lives. Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 10 All service users have access to the Advocacy service should they require it and they have assisted service users with the questionnaires. Detailed risk assessments were in place and these included actions to be taken by staff. The Registered Manager recognised the need for these to be updated and reviewed in line with care plans. The Registered Manager has updated the format and style of the risk assessments to reflect the service need. The previous risk assessments used were on the National Health Service model. The home has a system for reviewing service user care plans and these were fully recorded. Generally records were well presented, indexed, easy to navigate and to find the required information. Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 and 17. Quality in this outcome area is good adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported in making choices regarding their social and recreational life style, however little is provided in educational and learning processes limiting personal and developmental opportunities. EVIDENCE: The relationships observed between care staff and service users were open and friendly. The service users are encouraged to take pride in their appearance and their preferred style of dress is respected. During the visit the inspector spoke with the care staff about the activities service users were engaged in and the arrangements for these. Previously the home employed a member of staff to arrange suitable activities for the service users. However due to the reduction in service users this post was terminated. This should be reinstated as care staff cannot organise daytime activities and fully care for service users on a one to one basis. In the questionnaire completed several service users stated they would like more activities in the daytime; the majority of the service uses are fully Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 12 mobile. The care records of two service users provided detailed assessment and care planning information regarding their social, recreational, educational and occupational activities both within the home and outside in the community. Risk assessments on activities are in place. The Registered Manager stated that several of the service users are due to go on holiday to Blackpool. However due to the complex needs of some service users not all will be able to go. The home has made contact with the community city transport and dial a bus who arrange trips out. The daily routine is flexible with service users being supported to make their own decisions about how they spend the day. Service users are encouraged to remain as independent as possible subject to restrictions agreed in their care plan. Service users are encouraged as part of their individual care plan to be involved in cooking, shopping, house keeping and other social events. Service users who wish can have a key to their bedroom. Information on service users’ records indicated that contact with family and friends were appropriate. From examination of the menus and in discussion with the cook the home is providing a healthy well-balanced and nutritious diet. Service users are given a choice of meals and fresh fruit is available. A separate kitchen is available for service users to cook some meals and for drinks with staff supervision. However the Registered Manager stated that it’s not being fully utilised at present. From completed service users questionnaires service users did comment on the variety of the food offered. In discussions with the cook, the Directors compile the menus after discussions with the service users and are changed once every few months. As discussed with the Registered Manager a less formal approach is required and a in house approach rather than a formal meeting with Directors. The home is monitoring service users’ weight. Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health needs of service users’ are appropriately documented ensuring that individuals receive regular health checks. However the polices and procedures relating to the administering of medication are not being adhered to by the nursing staff leaving services vlunerable. EVIDENCE: From records examined and from discussions with staff, this showed that service users’ health and personal needs were being met Service users were generally healthy and records showed that staff promptly contacted the appropriated medical services. All service users attended services within the community including optician, chiropodist, and dentist. However the home needs to record these separately as currently they are recorded in the daily records. The home operates and monitors service users’ medication. None of the service users are able to administer their own medication. Staff have received training on medication procedures with the Registered Nurse on duty administering the medication. The arrangements for receipt, storage, Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 14 administration and disposal of medication were also examined and found to be satisfactory. There was a clear audit trail of all medication used at the home. However on examination of the administration of medication records one member of staff had failed to record the medication administered on the day for service users. This was raised at the last inspection as an issue and from the evidence seen this is still ongoing. As discussed with the Registered Manager a closer supervision of medication records is required and action must be taken to prevent this continuing. Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to safeguard service users’ welfare and ensure that their concerns are listened to and acted upon. EVIDENCE: The home has a complaints procedure and a summary of the procedure is included in the service user guide, and is display around the home. The complaints procedure was examined and includes the current contact details for the Commission for Social Care Inspection. The home’s whistle blowing policy is linked to the complaints procedure. Complaints tend to be dealt with at an informal level, which results in the home receiving very few formal complaints. The home has not received any formal complaints in the last year and the Commission has received no complaints for this service. From discussions with service users and from completed questionnaires, stated they knew who and how to make a complaint. The homes policy on the protection of adults was examined. This needs to be reviewed and updated to reflect the change of emphasise to the Safeguarding of Adults. The home operates to the Derby City and Derbyshire Safeguarding procedures. From discussions with the Registered Manager and from records examined there has been one reported incident since the last inspection. This was investigated by Derby City Social Services Department under the Safeguarding of Adults procedures and found to be satisfactory. Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 16 The Registered Manager reported that all but one staff member who has just been appointed had completed the training on Safeguarding of Adults. The Registered Manager stated that staff had received training on approved physical intervention techniques. Certificates were on staff personnel records, which confirmed which staff had completed this training. Cleeve Villas DS0000061805.V332817.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): Standards 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The general standard of the home and the environment was satisfactory providing service users with a comfortable place in which to live. EVIDENCE: A tour of the home was undertaken and all communal areas were inspected together with the staff facilities. The tour of the home showed that the home is maintained and furnished to a satisfactory standard. Several of the service users’ bedrooms and en suites were inspected with their agreement. Several of the service users’ had personalised their bedrooms with some of them bring their own furniture. The majority of the service users’ bedrooms were decorated in the same colour of white, perhaps reflecting its previous institutional status. As part of moving in to the home and personalising their bedrooms service users should be given the opportunity to re decorate their bedrooms. The home is in the process of having a lift fitted, with the work commencing within the next few weeks. The lift is being installed in the small downstairs Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 18 lounge and will need decorating after the work is completed. This room was highlighted at the last inspection as requiring decoration. As annual maintenance programme for renewal of the fabric and decoration of the premises needs to be produced and implemented with records kept. This will assist with the overall maintenance of the home. Service users have access to the grounds outside and patio the area. The home has a dedicated smoking area to the rear of the home The facilities are comfortable and free of unpleasant odours as was the case on the day of the visit. The home has appointed one member of staff to take the lead on infection control and liaises with Derby City Primary Care Trust. As stated at the last inspection care staff are still having to clean when the ancillary staff are on leave, which does distract from the work they do with the service users. These arrangements need to be reviewed as a matter of urgency. Cleeve Villas DS0000061805.V332817.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): Standards 32,33, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has robust recruitment procedures and practices in place which ensure the safety and protect the service users. However these are not always being adhered to. Service users are well supported by an effective staff team who are appropriately trained. EVIDENCE: The home operates a key-worker system and the staff spoken with during the visit were aware of the individual needs of the service users. From records examined during the visit the care staff have attained or are working towards a National Vocational Qualification at level II or level III. From records examined at the home and from the Pre Inspection Questionnaire the home also employs six Registered Nurses. On examination of the Pre Inspection Questionnaire and from the staff rota the home currently works on three care staff per shift. However from the inspection and the Pre Inspection Questionnaire it was not possible to establish whether sufficient care staff are employed to meet the needs of the service users. The Registered Manager did not have the information on the level of need of each service user nor the staff hours allocated to them as based on the guidance in the Residential Forum. The Directors of the Company maintain this information. Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 20 As discussed with the Registered Manager the home needs to look at staffing levels in relation to the needs of the service users. From observation of one service user and from discussions with the staff, three care staff were needed to assist with getting up in a morning. A sample of staff records was examined, and although the majority of the information was available staff records do require attention. Staff recruitment records available need to meet the requirements under Schedule 2 of the National Minimum Standard for Care Homes for Adults (18–65) 2001. The staff recruitment records did highlight the following issues: • Records of interviews were not on file. • Proof of identity. • Full employment history. • Reference details were not clear. The staff training records were examined. There is a programme of training in place, which includes fire safety, first aid, health and safety, moving, and handling, SKIP and learning to care for people with a learning disability and mental illness. From discussions with staff training is seen as important and they are encouraged to attend relevant courses. From examination of the staff rota the Registered Manager has very little management time within his contracted hours and is required to provide nursing cover; as a result of this some management duties have not been fully addressed. One of the areas is staff supervision. Although there is a system, policy and procedure for the supervision of staff the Registered Manager confirmed that this does not always take place. Staff confirmed that they do have an appraisal and evidence of this was seen on staff personnel records however there was no Personal Development Plan Cleeve Villas DS0000061805.V332817.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): Standards 37,39, 40 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Quality assurance systems are in place to ensure that service users have a voice and their views are listened to. However current practice requires further development. EVIDENCE: The Registered Manager has considerable knowledge and experiences in caring for adults with a mental disability and challenging behaviour. He has been at the home for a number of years. As discussed at the visit the Registered Manager does not have a recognised managers award, which all managers of care homes are required to achieve. Currently the Registered Manager has a relevant job description setting his responsibilities but has not been issued with a contact of employment. The Registered Managers have developed a policy for monitoring care provided by the home. This is conducted jointly with the owner and includes Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 22 questionnaires and residents meetings. As discussed with the Registered Manager the review on the quality of care could be extended to include stakeholders. During the inspection the Registered Provider reports were seen and confirmed that the visits have been undertaken. However the information in these reports was limited. Samples of policies were examined and have been discussed with the Registered Manager, several need to be reviewed and updated. The staff have access to all the policies and procedures. A sample of service/maintenance records was examined (including gas and electricity services) and there was confirmation that all the equipment had been properly maintained. Evidence of checks having been carried out was provided to the Commission for Social Care Inspection Systems were in place for the monitoring and maintaining the hot water temperatures. The water system has been tested for E Coli and Legion Ella. The service contact fro the nurse call had expired. Cleeve Villas DS0000061805.V332817.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 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 2 X 2 X Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 24 YES 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 YA12 Regulation 16 There must be a daily activities programme, which service users can access, giving them opportunities for education and learning. The home must have sufficient staff available to organise a programme of daily activities for all service users. The home must ensure that staff are approved to administer medication and sign the appropriate records for each service user. Systems must be in place to ensure that staff have correctly administered and recorded all medication given to service users. The homes policy on adult protection must be revised and updated to reflect current practice The home must have an annual planned programme for the renewal of the furniture, fittings and decoration, with records as to when this will be achieved. The home must have a sufficient DS0000061805.V332817.R01.S.doc Timescale for action 30/06/07 2. YA12 18 30/06/07 3. YA20 13 31/05/07 4. YA20 13 31/05/07 5. YA23 13 31/05/07 6. YA24 23 30/06/07 7. YA33 18 31/05/07 Page 25 Cleeve Villas Version 5.2 8. YA34 19 Schedule 2 and 4 number of staff to meet the assessed need of the service users its cares for and this must be in line with the Residential Forum. All staff employed must comply with the home policy and procedures on recruitment as detailed in Schedule 2 of the National Minimum Standards for Younger Adults 2001. This is a previous requirement. All staff must have regularly supervision in line with the National Minimum Standard 6.4. This is a previous requirement. 30/06/07 9. YA36 18 31/05/07 10. YA39 26 11. YA39 24 12. YA42 23 The Registered Provider following 30/06/07 the unannounced monthly visit must provide a comprehensive report in to the care management, and running of the home. As part of assessing the quality 30/06/07 of care provided by the home consultation with stakeholders and service user representatives must be undertaken. The home must have a valid 31/05/07 service certificate for the nurse call system RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA18 Good Practice Recommendations Service user and their families should be given the opportunity to sign their care plan. This is a previous recommendation. The Registered Manager Person should ensure that any evidence of a medication error by a nurse is reported to DS0000061805.V332817.R01.S.doc Version 5.2 Page 26 Cleeve Villas 3. YA24 the Nursing Midwifery Council. Suitable arrangements should be in place to cover when the ancillary/ cleaning/ staff are not available. This is a previous recommendation. When gaps in employment history is investigated this should be formally recorded on interview minutes. This is a previous recommendation. The Registered Person should ensure that individual staff interview records are signed and dated. This is a previous recommendation. The Registered Person should ensure that the full employment history includes the days date month and year of employment This is a previous recommendation. The Registered Managers should commence an approved management qualification. This is a previous recommendation. The Registered Manager should have an employment contract detailing the terms and conditions of his current employment. All polices and procedures relating to the operation of the home should be reviewed and updated. This is a previous recommendation. 4. 5. 6. YA34 YA34 YA34 7. 8. 9. YA37 YA37 YA40 Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Cleeve Villas DS0000061805.V332817.R01.S.doc Version 5.2 Page 28 - 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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