Inspection on 27/04/06 for Clover Residents

This inspection was carried out on 27th April 2006.

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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Clover Residents 18/09/07

Clover Residents 12/01/06

Clover Residents 23/05/05

Clover Residents 13/10/04

Clover Residents 24/05/04

Clover Residents 01/12/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Townley Road, 2-3

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Clover Residents 2 Dorchester Drive Bedfont Middlesex TW14 8HP Lead Inspector Sarah Middleton Unannounced Inspection 27th April 2006 11.50 Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 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 Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Clover Residents Address 2 Dorchester Drive Bedfont Middlesex TW14 8HP 0208 893 1123 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) Ms Deborah Selley Ms Denise Pryme Denise Avril Pryme Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (0) of places Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: Clover is a three bedded home for three service users. It is registered for people with learning disabilities. The home is a detached bungalow, situated in a quiet cul-de-sac. It is within easy walking distance of Bedfont, where there are shops and public transport links. Hounslow town shopping centre and Feltham leisure facilities can be easily accessed from the home. Accommodation includes a large lounge/dining room and three single bedrooms. There is one bathroom with a toilet for three service users. The bedrooms do not have washbasins. The office/sleeping - in room has its own shower and toilet. There is a small garden around the bungalow with seating. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. The inspection of the home took place between 11.50am-5.50pm. The Inspector spoke with one member of staff and two service users. It must be noted that it is sometimes difficult to ascertain the views of service users with learning and communication difficulties. There were no visitors at the time of the inspection. There were no service user or staff vacancies at the time of the inspection. The Registered Manager was present and assisted with the inspection process. The Inspector would like to thank staff and service users who contributed to this inspection process. All of the key Standards were assessed at this inspection. The home had met five of the previous requirement and six new requirements were made following this inspection. Previous timescales have also been included in this report for requirements that are still outstanding. What the service does well: What has improved since the last inspection? The home has made improvements in reviewing care plans on a more regular basis. This enables staff to reflect on service users needs and to incorporate any new identified needs into a revised care plan. Polices were available for infection control. The home had completed a risk assessment with regards to the shower in the office. Service users do not use this shower, but the Registered Manager carried out a risk assessment to ensure service users health and safety is protected. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 6 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. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 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 Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 4 Pre-admission assessments are carried out to ensure the home can meet their identified needs. The home is attempting to meet the needs of the new service user. It is questionable whether this can be done on a long-term basis with only thirty hours additional funding to meet the communication needs of the service user. Prospective service users and their representatives are encouraged to visit the home to make an informed choice about moving in. EVIDENCE: The home had admitted a new service user four days prior to the inspection. The home had received little information from the previous home the service user had lived in and no assessment or care plan from the local authority that had referred the service user to the home. However the Registered Manager had met with the new service user and completed a pre-admission assessment on the information they could obtain. This assessment covered areas such as the service user’s abilities, any behaviour issues and risk assessments. The Inspector advised the Registered Manager to consider for future reference the benefit of obtaining a full social services assessment, as this might have assisted with the planning and pre-admission process. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 9 The Registered Manager confirmed they would always visit the prospective service user to ensure the home can meet their needs and this is put in writing to the referrer and/or the service user. The new service user speaks very little English therefore prior admission the Registered Manager obtained additional funding for thirty hours a week for a Somalia worker to support and get to know the service user. This worker is assessing the words the service user understands and is feeding this back to the main staff team who are using certain words, in the service user’s first language, with the aim to have some dialogue with this service user. This is particularly important for when the additional worker is not available. This placement is to be reviewed in the next few weeks and the Inspector discussed with the Registered Manager the need to ensure they feel confident that the home can meet all of the service user’s needs. The Inspector observed the service user talking to staff and to the Inspector and for the most part staff and the Inspector could not understand what the service user were saying to them. The home must seek to obtain additional funding on a long-term basis and if possible increase the hours to fully support the service user successfully. The Registered Manager acknowledged the need to carefully monitor the next few weeks to ascertain if the placement would be appropriate. Although the Inspector recognised the home had put measures in place to meet the new service user’s needs and it was only the fourth day since they had been admitted, a requirement was made for the home to be able to demonstrate how they can fully meet the new service user’s needs. The Registered Manager confirmed the new service user had made several visits to the home along with their family. They made day visits and overnight stays before moving into the home. The other two service users were consulted regarding a new service user moving in and are trying to adjust to living with a new person. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 The personal and social care needs of service users had been identified and were being met. Service users have the opportunity to make decisions about their lives and how they spend their time on a day-to-day basis. Shortfalls in the completion of risk assessments relating to individual service users needs had been identified and were to be addressed. EVIDENCE: Individual service user care plans were available and samples were viewed. Overall these were comprehensive and detailed how the service user’s identified personal and social care needs would be met. The home had begun to complete a care plan on the recently admitted service user. The home completes a profile of the service user which includes likes and dislikes and then outlines in more detail the support and prompting the individual requires from members of staff. Other relevant areas such as the activities they enjoy and religious needs are also included into the care plan. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 11 The care plans viewed were up to date and the home carries out six monthly and annual reviews and makes any adjustments accordingly. Daily records were viewed and these detailed the care provided. Service users living in the home do not have independent advocates. Staff asked described how service users are encouraged to make decisions throughout their daily lives. The culture within the home is to promote as much choice and opportunities for service users and to encourage them to make decisions wherever possible. Samples of risk assessments were viewed and these covered a variety of areas in a service user’s life such as road safety awareness and approaching unfamiliar people. However there were no risk assessments in place regarding those service users who have a fear or reluctance to visit health professionals such as a dentist or GP. This was discussed with the Registered Manager who confirmed this would be addressed. A requirement was made regarding the completion of risk assessments for all potential hazards and risks to a service user’s life. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Social activities were in place and provided stimulation and occupation for the service users. Engaging with community facilities form part of every day life for the service users. Visiting by family or friends is encouraged contact to ensure relationships are maintained. Service users rights are respected by staff and are promoted throughout daily life. Meal provision offers service users choice and variety to maintain a healthy weight. Service users are encouraged to take part in the cooking of meals in the home, thus developing and keeping independent skills. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 13 EVIDENCE: The two service users who have lived in the home for several years attend local day centres. One attends five days a week the other three days a week. The new service user, for some of the day, has one to one support and staff have been getting to know this service user’s interests. Service users are not able to seek employment although one service user has a voluntary job once a week at a church. Service users choose when to do their personal shopping, clean their room and do their own laundry, all with the support and assistance, where necessary, of staff. Service users asked said they kept busy each day doing different things and that they enjoyed going to the day centres. Staff confirmed the local community are friendly with the service users and engage with them. The home is situated on a small cul-de-sac road where most of the neighbours speak with the service users. One service user can travel independently if it is to a place they are familiar with. Staff usually escort the service user several times to a specific place to ensure they are confident the service user knows the route and bus to take to reach the destination. Family contact is encouraged wherever possible and service users have access to a payphone to call family members. Two of the service users lock their bedrooms to ensure they have privacy. They explained to the Inspector the reasons for locking their rooms was the need to keep anyone else out from entering their bedroom. There had been some issues with the new service user who had been entering other service users bedrooms, staff were aware this had been a problem in the first few days of their admittance. The Registered Manager confirmed two of the service users receive their own personal mail, but as they are not able to read, staff then read the contents to them. Staff were seen to interact with service users throughout the inspection in a positive and appropriate manner. Service users are encouraged to assist with the preparation of meals and to choose the meals they would like. Individual meals are recorded and likes and dislikes are noted. The kitchen was clean and tidy at the time of the inspection. Fridge/freezer temperatures had been taken on a regular basis and were within an appropriate range. The new service user eats Halal foods, although the family did not request for any other special measures to be put in place, such as separate crockery and cutlery. The home is consulting with the family to ascertain if they wish for the Halal food to be stored in a separate small fridge. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 14 The Inspector discussed with the Registered Manager the development of a Halal policy so that staff and the home’s statement of purpose is clear about what they can and cannot provide in relation to special diets or religious beliefs. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Service users receive as much support as they need with their personal care. Health needs are identified and where possible are being met. Difficulties in meeting health needs are to be recorded on care plans and risk assessments to ensure the health and welfare of service users is monitored. Medication systems are to be put in place to clearly identify if there are any errors regarding administering or recording medication. EVIDENCE: Service users require some assistance with personal care such as running the bath and checking the temperature of the water. This is noted on care plans, with information regarding the level of support each service user needs. Personal care and bathing is carried out in private. Those service users asked confirmed they can choose the clothes they wear and the times they get up and go to bed. Health needs are noted on care plans and all service users have a local GP. There are some difficulties in encouraging one of the service users to see particular health professionals, evidence was sent that staff had consistently tried to make appointments but the service user then usually refused to attend the appointment. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 16 This was discussed with the Registered Manager as although the home were clearly trying to meet all the health needs of the service users, as noted earlier in Standard nine, if certain identified needs cannot be met, the home must carry out a detailed risk assessment to ensure staff take all the necessary steps in monitoring the health needs of the service user. This is a combined requirement along with Standard nine. Medication systems were assessed. Service users do not self medicate and there were no controlled drugs stored in the home. Staff members receive medication training from the local pharmacist. Two staff check and administer medication. The “as and when” medication, Paracetamol was counted and two were found to be missing and had not been accounted for. This error could not be explained. A requirement was made that any loose or un-blistered medication must be regularly counted to ensure any errors are identified as soon as possible. The medication had not been counted for several months and this shortfall must be addressed within the home. All other medication administration records viewed had been completed correctly. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The home has a clear complaints procedure and service users asked were confident they could voice their concerns and/or complaints to Management. Systems were in place for the protection of vulnerable adults. EVIDENCE: The home has a detailed complaints policy and service users asked were aware they could talk to the Registered Manager if they had any concerns. The home had not received any complaints and the CSCI had not directly received any complaints. The Registered Manager had attended a one day course on the role of investigating adult protection issues and had recently attended a course on the subject of safeguarding adults from abuse. The staff team were due throughout the forthcoming months to also attend this course. There had been no adult protection issues at the home. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 & 30 Service users live in a well-maintained and homely environment. Service users bedroom offer them the privacy away from others to relax and to have their personal possessions around them. The home was clean and presentable at the time of the inspection. The training on health and safety/infection control will be put in place to ensure staff are up to date with issues relating to this area. EVIDENCE: A tour of the home was carried out and a sample of rooms viewed. These were being satisfactorily maintained. The home was bright, modern with good furnishings and furniture for the comfort of the service users. The Registered Manager confirmed she replaces items and updates rooms on an as and when needed basis. Two service users showed the Inspector their bedrooms. These were single rooms that had been personalised with pictures and photographs. The service users said they liked their rooms and were able to have privacy through locking their rooms. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 19 The laundry facilities were located in a separate room next to the kitchen. Service users are supported to do their own laundry. Staff had not attended a health and safety course, to include procedures to minimise the spread of infection, for some time. This was made a requirement. The home has a policy on infection control, which is available for staff to refer to. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Staff are competent and work well together in the interests of the service users. Overall the systems for the recruitment of staff were robust and safeguarded service users. The home is aware of the need to identify training and to renew training for staff on a regular basis. Shortfalls are to be addressed to ensure staff have the necessary knowledge and skills to meet the varied needs of the service users. EVIDENCE: The staff team is small and have worked together to meet the needs of the service users. The team is a mixture of ages, ethnic backgrounds and gender. The Inspector observed staff with service users and found them to be comfortable amongst each other. Staff were motivated to engage with the service users, although as noted earlier, there are difficulties in communicating with one of the service users. The home promotes staff to study for an NVQ and the home is meeting its target of over 50 of the team either studying for this qualification or some have already obtained an NVQ. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 21 Staff spoken with stated the team works well together and communicates effectively with each other. The staff team meet every two months and minutes were seen to evidence the discussions that had taken place. Those asked felt that there were sufficient numbers of staff working at any one time. The staff employment files viewed contained completed application forms, CRB disclosure numbers/certificates, two references and identification. As some staff work across the homes owned by the Registered Manager, who is also the Registered Provider, the Inspector reminded her that all required documentation must be available for inspection. In addition the Inspector discussed with the Registered Manager the need to check for any employment gaps and to obtain a detailed work history on future applicants to ensure the home safeguards the service users at all times. Staff stated the training and induction they receive was of a high standard. New members of staff shadow existing members of staff until they feel confident to work unsupervised. An induction checklist was viewed that all new employees work through. The Inspector viewed the training staff had attended, staff had received mandatory training, although some of this was out of date, as noted earlier the health and safety training was out of date. A requirement was made for a clear system to be developed to identify when training is due to be renewed. In addition, if the new service user, who has Autism, remains living in the home, the Inspector discussed with the Registered Manager the need to identify appropriate training on this subject to ensure staff are competent and confident to successfully understand and support this service user. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Service users and staff benefit from a well run home. The systems for reviewing the quality of care and including service users opinions are to be addressed in order to demonstrate areas working well in the home and areas that need attention. The shortfalls in servicing records could pose a risk to service users, staff and visitors safety. EVIDENCE: The Registered Manager/Provider has been in post as the Manager for four years and had obtained an NVQ level 4 in management and care. Staff asked said she was approachable and flexible in her approach as the manager. The home had not put in place a system to monitor and report on how the quality of care is reviewed. Service user surveys had not been carried out for over a year and the home had not begun to look at areas that work well or areas that need improving. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 23 Discussions took place with the Registered Manager regarding how the home could begin setting up this procedure. A re-stated requirement was made that service users must be consulted with regarding their views on the home and the home must review certain identified areas that can be monitored on a regular basis. From thereon a report of the review along with the any relevant findings must be available for service users and the CSCI. The annual development plan had not been completed. The Registered Manager was confident that this would be finished within the next few weeks. This was made a re-stated requirement. Samples of servicing and health and safety records were viewed. The Gas Safety, fire equipment and Portable Appliance testing were all up to date. Fire drills had been held on a regular basis but not at different intervals, a requirement was made that they must be held at various times of the day and night. Water temperatures had been taken on a regular basis and risk assessments had been completed on the shower room that is in the sleeping in room. The testing for Legionella was out of date and a requirement was made for this to be carried out by a relevant professional company. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 24 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 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 3 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 x 2 x x 2 x Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 25 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 YA3 Regulation 14(2), 15(1) Requirement Timescale for action 03/07/06 2. 13(4)(c) 3. YA20 13(2) 4. YA35YA30 18(1)(c)(i) The home must be confident they can meet all of the identified needs of a new service user admitted into the home and evidence must be available as to how the home will meet these needs. Risk assessments must be 31/05/06 completed if service users refuse to attend health appointments. Staff must be aware of how to address this issue. Medication systems must be put 31/05/06 in place to identify any errors in the administering and/or recording of medication. Loose medication must be counted on a regular basis. Staff must receive health & 31/05/06 safety training & any other training that is out of date. Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 26 5. YA39 24 The home must implement full quality assurance and monitoring systems & include service user’s views in the overall report of the findings of the review. Previous timescale 31/03/06 not met). The annual development plan must be revised and updated and/or a new annual development plan must be produced for this year. (Previous timescale 31/03/06 not met). 31/08/06 6. YA39 24 30/06/06 7. YA42 8. YA42 13(4)(a)(c) The testing for Legionella must be up to date and evidence must be available to demonstrate the home is free from Legionella. 23(4)(e) Fire drills must be held at various intervals, including evenings/night. 05/06/06 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clover Residents DS0000022908.V286819.R01.S.doc Version 5.1 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. 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!