Inspection on 18/01/06 for Coxwold and Priory

This inspection was carried out on 18th January 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coxwold and Priory 10/03/09

Coxwold and Priory 27/03/08

Coxwold and Priory 17/01/07

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Coxwold and Priory 9 Coxwold Grove Hull East Yorkshire HU4 6HH Lead Inspector Christina Bettison Unannounced Inspection 18th January 2006 09:30 Coxwold and Priory DS0000064809.V279295.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 Coxwold and Priory DS0000064809.V279295.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. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Coxwold and Priory Address 9 Coxwold Grove Hull East Yorkshire HU4 6HH 01482 329226 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) Avocet Trust Carl Ince Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Carl Ince is registered for 17 Priory Grove, 33-35 Priory Grove and 9 and 9a Coxwold Grove and only undertakes managerial responsibilities for 186 Marlborough Avenue, Hull until 12th September 2005 and Flat 2 and Flat 3, 23 Trippett Street, Hull for up to 6 months from the date of registration. 22/7/05 Date of last inspection Brief Description of the Service: Coxwold and Priory consists of 5 separate houses. They are all part of the Avocet Trust organisation. Avocet Trust is a registered charity. 9 and 9a Coxwold Grove are registered to provide care and accommodation for three adults with a learning disability in each house. The houses are in Gipsyville close to the Hessle Road shopping area to the west of the city. Both houses are three bedroom detached houses. Each house has a large sitting room, kitchen/diner, a large rear garden and a driveway to the front with parking space. The integral garage had been converted into an extra downstairs room with the addition of ensuite facilities including a walk-in shower. Upstairs there are 2 bedrooms, (1 has ensuite facilities including a shower) a separate bathroom and the third bedroom was being used as a store room/office/sleeping in room. There are shops, pubs, medical centre and post office all within walking distance. Public transport to various parts of the city is easily accessible. 33-35 Priory Grove consists of two separate houses and is registered to provide care for 5 service users. The home is situated within a housing estate to the west of the city that has recently been developed. Both units comprise of single storey accommodation. One unit is for one person and the other for four people. The unit for one has a lounge, kitchen/dining room, bedroom, bathroom and utility room. The larger unit has four single bedrooms, a sensory room, kitchen, lounge / dining room and utility room. Both have their own garden and separate private entrance. There are a number of shops, a post office, park and medical centre within walking distance. Public transport to various parts of the city is easily accessible and in addition some of the service users have their own car arranged through their mobility benefits. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 5 17 Priory Grove is registered to provide care and accommodation for one adult with a learning disability. The house is in Gipsyville close to the Hessle Road shopping area to the west of the city. 17 Priory Grove is a three bedroom semi-detached house. There is a large sitting room, kitchen/diner, a large rear garden with some landscaping and a driveway to the side with parking space. Upstairs there is a bedroom, bathroom and small sitting room for the service user, and a sleeping-in room for night staff. There are shops, pubs, medical centre and post office all within walking distance. Public transport to various parts of the city is easily accessible. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The services at Coxwold and Priory were registered as one service in November 2005. The inspection took place over 6 hours and was an unannounced inspection. A tour of the houses took place, staff files, care records, policies and procedures, staff lists and training records were all examined. The registered manager, senior support workers and staff were spoken to. Service users that were at home on the day of inspection were spoken to, care practices and interactions were observed. This report should be read together with the previous inspection reports as the majority of national minimum standards were assessed at the previous inspection. What the service does well: What has improved since the last inspection? Service users individual plans and all records relating to care provided have improved; individual plans were available for all service users that were detailed, up to date and the majority had been reviewed. There was evidence that service users were enabled to access health care provision. Service users are supported to make and attend health care appointments and records are maintained to evidence this. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 7 A contract / statement of terms and conditions that meets the requirements of this standard has been developed and has now been agreed with service users and / or their representatives. Senior staff have completed a training audit for each house to enable them to identify staff training needs. Recruitment practices have improved; all staff now have CRB clearances, references and ID as required by regulations, this means service users are protected from harm. The majority of staff have completed in house protection of vulnerable adults training to ensure that service users are protected from harm. 50 of staff are qualified to NVQ level 2 and some staff to NVQ level 3. The policy/procedure for the use of restrictive physical interventions had been produced to ensure that staff are aware of their responsibilities and are able to protect service users from harm. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 8 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 9 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 Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 10 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): 2,5 Service users needs are assessed ensuring that staff are given enough background information in which to develop detailed individual plans and therefore meet service users needs. Service users all have a statement of terms and conditions thereby ensuring that they are in receipt of information as to the type of service they should be receiving. EVIDENCE: NMS 1 and 4 were met at the previous inspection; therefore they were not assessed at this inspection. At the previous inspection there had been one new admission to 9a Coxwold grove. At that inspection it was evident that the home did not have a copy of the assessment or care plan from the care management team neither had the home developed an individual plan/IPP. Since that inspection the home had received copies of the community care assessment, the care programme assessment, care plans and regular CPA reviews were being undertaken. The senior support worker had developed a Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 11 detailed individual plan and behaviour management guidelines for all staff to follow and provide a consistent approach. A contract / statement of terms and conditions had been developed since the previous inspection and has now been agreed with service users and / or their representatives. A sample of these was seen as part of the inspection process. Those seen were produced in large print and with pictures to support the written text. Advocacy services from Mencap support service user to understand the content and the type of service they can expect to receive. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 12 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 Service users have detailed individual plans/IPP that ensure their specific needs and goals are met and enables them make decisions as much as they can. EVIDENCE: Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 13 At the previous inspection it was identified that for some of the service users at some of the houses did not have an up to date individual plan. At this inspection 2 care files from 9 Coxwold Grove, 1 care file from 9a Coxwold Grove, 1 care file from 33 Priory Grove, 1 care file from 35 Priory Grove and 1 care file from 17 Priory Grove were all examined. Since the previous inspection individual plans had been developed to cover all aspects of assessed needs, these were found to be detailed and up to date. Service users have a member of staff who act as their key worker and are responsible for developing Individual Program Plans (IPP) for each service user. Staff were able to confirm that the plans were kept under review and that they were formally reviewed every 6 months. Copies of the notes from reviews were seen to support this. Where service users display behaviours that can be difficult to manage and specific techniques or methods of communication are required in order to minimise the risks behaviour management strategies are now in place. Detailed risk assessments are in place that covers all activity that may pose a risk to service users and/or staff. These had been regularly updated. Policies and procedures have been updated and amended to support the need for physical interventions and the majority staff had been trained in the appropriate techniques of restrictive physical interventions. It was clear from discussion with the manager and from records that advocacy services are accessed to support service users. Avocet Trust also hold best of interest meetings to support decision making for service users. Care files for all service users would benefit from tidying up. Each service user has at least four different files and some of the information is out of date and could do to be archived. Staff need to ensure that all individual plans, behaviour management guidelines, and records are all signed and dated and presented in a legible way. Also one service user was having his behaviour routinely monitored when there had been no significant issues for quite some time. This appeared to be unnecessary practice. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 14 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): 11,12,13,15,16,17 Service users are assisted to continue their personal development and have access to the community for a wide range of leisure pursuits. Family contact is maintained and all service users enjoy a healthy diet. EVIDENCE: The inspector was informed that none of the service users are engaged in work placements however all of the service users engage in a wide range of activities to continue their opportunities for personal development. Some service users attend local authority day services and some attend Avocets five senses day service and take part in activities such as keep fit, IT, art and communication skills. Service users enjoy an active social life which is detailed in their individual care files, such as bowling, swimming, shopping, visits to the hairdresser, walks and out for meals at the pub, visiting friends, two of the service users support Hull City AFC and have a season pass. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 15 For two of the ladies who have autism their activity timetables are produced in a colour coded symbolised version and a copy kept in the service users room to remind of them of their activities for the week and ensure that their routine and structure is adhered to. Service users are supported to either visit their parents/relatives homes or are visited by them at there home and contact is welcomed. The manager and staff promote a healthy eating menu but try to balance this with service users likes/dislikes and special treats on occasions. Any restrictions are clearly documented in the care file and where possible agreed to by the service user. Some of the service users have been assessed by the dietician and the home follow the recommendations given. During the inspection the inspector observed a service user sitting on a member of staffs knee and being cuddled like a baby or young child. The inspector had observed this on another occasion. It was discussed with the manager and senior support worker as it was felt by the inspector to be unacceptable practice and not promoting the service users adult status and not treating him with dignity and respect. The inspector advised that the staff develop a desensitisation programme to gradually reduce this behaviour and to provide the service user with the physical contact that he likes in a more age appropriate manner or alternatively hold a best interest meeting to determine the way forward. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 16 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): 20 Service users health needs are met however there is inadequate medication training provided to staff and unsafe storage and recording of controlled medication, leading to service users being placed at risk. EVIDENCE: NMS 18 and 19 were met at the previous inspection; therefore they were not assessed at this inspection. There are currently no service users self-medicating. There are written policies and procedures in place for staff to adhere to regarding administration of medication. The manager confirmed that most of the staff had completed some of the modules for the administration of medication provided by the local authority however at the time of the inspection this had not been completed therefore it remains an outstanding requirement. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 17 The registered person must ensure that all staff completes the training and a competency check or a workbook is completed following the training to ensure staff understand their responsibilities. There was evidence of regular liaison with the Psychiatrist, clinical psychologist and the continuum team regarding the management of one of the service users behaviours. The service user had recently been prescribed a controlled drug to be administered PRN by staff. There appeared to have been some confusion about when and why this medication should be administered and there had been no written instructions provided by the health professionals/psychiatrist. The senior support worker must ensure that there are written guidelines/protocol for staff to run alongside the behaviour management plan to give staff clear unambiguous guidance as to when PRN medication should be administered. The home did not have a controlled drugs cabinet that complies with the “Misuse of Drugs Act 1971” and a controlled drugs register. This must be addressed. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 18 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): 23 The staff team are aware of the Protection of Vulnerable Adults policies and procedures and their responsibility within these, thereby service users are protected from abuse, neglect and harm. EVIDENCE: NMS 22 was assessed and met at the previous inspection and there had been no complaints made to the home or the CSCI since then, therefore this standard was not assessed at this inspection. Since the previous inspection the senior staff have provided in house briefings for all staff to inform them about the Protection Of Vulnerable Adults Policies and Procedures and their responsibilities within this. Staff members have to complete a questionnaire following the training to demonstrate their understanding. If the senior staff have any concerns with regard to any staffs understanding they will ask then to undertake the training again or pick it up in supervision. The inspector examined both the training pack and individual questionnaires, which evidenced good practice and linked in with the multi agency guidelines. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 for 17 Priory Grove only In the majority of the houses service users are provided with attractive and homely environments in which to live with the exception of 17 Priory Grove which would benefit from redecoration throughout. EVIDENCE: NMS 24-30 were all met at the previous inspection for 9 and 9a Coxwold Grove and 33-35 Priory Grove therefore they were not all assessed at this inspection. At the previous inspection it was not possible to inspect the premises at 17 Priory Grove as the service user was out for the day and his house was locked up. At this inspection NMS 24 and 30 were assessed for 17 Priory Grove only. The inspector found the house at 17 Priory Grove to be dingy and uninviting. The décor was old fashioned and because of the small windows and dark wood in the house, it was dark. Carpets were worn and the majority of the furnishings were old and required replacing. The inspector was informed that the living room had recently been painted and two new settees and stereo system purchased however despite these improvements the house would benefit from total redecoration, new carpets and some new furniture. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 20 Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Service users are cared for by a staff group, which is sufficient in numbers and who are well trained to meet their needs, however there is inadequate supervision provided and a lack of planning regarding training. EVIDENCE: NMS 31 and 33 were assessed and met at the previous inspection therefore they were not assessed at this inspection. For the two service users that have moved from Marlborough Ave to 9 Coxwold Grove the staff team who know them well have transferred with them. This has given the service users a sense of stability and consistency and the staff spoken to confirm that the service users have settled into to their new home very well. Recruitment practices have greatly improved; all staff now have 2 written references and CRB clearances this means service users are protected from harm. The senior staff have commenced annual staff reviews and have completed a staff training audit which evidences were there are gaps in staff skills, they Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 22 have requested places on training courses to meet these skills gaps and staff have attended some training; most staff have completed modules of the medication training provided by the local authority and all staff have had an in house POVA briefing. All certificates for training completed are now being held on site. The manager still needs to ensure that all staff are up to date with mandatory training, to include infection control. Out of a staff group of 31,16 staff have got NVQ level 2 or above and 10 staff are registered and working towards their NVQ level 2 or 3. During the inspection it was evident that staff respected service users. It was evident from discussion with staff that they felt they were able to meet the service user’s needs. There was no training plan for the home, however the training records were much improved. The registered person must ensure that a training plan is developed for the staff team in the home and that all staff have an individual training profile, these remain outstanding requirements. New staff had been appointed since the previous inspection; there was no evidence of induction having been carried out. The inspector was informed that this will be commencing in January 2006.The registered person must ensure that all new staff receives induction training that meets LDAF standards this remains an outstanding requirement. The manager and senior staff had commenced a supervision schedule however of the staff files examined not all staff had had regular recorded supervision, this includes the manager therefore this remains an outstanding requirement. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,42 Service users are encouraged on an informal basis to contribute to how the home is run. A formal approach has been devised but not yet fully implemented. The policies and procedures are out of date and do not reflect current practices in the home. Service users live in a safe environment however the lack of some maintenance certificates compromises this. EVIDENCE: NMS 38,39 and 43 were assessed and met at the previous inspection; therefore they were not assessed at this inspection. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 24 The Registered Manager has been away from the home for a short while managing another of Avocet,s services. However he was at the home on the day of inspection and presented himself as helpful,friendly and approachable throughout the inspection. During his absence two of the senior support workers have been acting up as managers and appear to have managed very well. The inspector was assisted on the day by the registered Manager, two of the acting up managers and one of the senior support workers who were all very helpful and knowledgable and responded to advice and suggestions from the inspector in a positive way. There was suitable insurance cover in place. Avocet have developed a quality assurance system however this has not yet been fully implemented within the home, this means that service users and their families views are not yet utilised to help shape the way the service is provided in the future. As part of the previous inspection the maintenance records were examined and those seen were in order, with the exception of the electrical hard wiring certificate and the gas safety certificate for the boiler. They still could not be located at this inspection this remains an outstanding requirement from previous inspections. (9 and 9a Coxwold Grove) Policies and procedures were examined as part of the previous inspection since then some have been updated, one of these being the use of physical interventions. The quality assurance manager is making steady progress in reviewing and amending the policies and procedures in line with changes in legislation and best practice guidance and the timescale for completion has been agreed at 31/1/06. Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 3 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 x 34 3 35 2 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 2 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 2 3 3 x x 2 x 2 x Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 26 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 YA11 Regulation 12 4 a 12 5 b Requirement The registered person must provide service users with the opportunity to develop social, emotional, communication and independent living skills for personal developement into adult status. The registered person must ensure that all staff responsible for administering medication have receieved training and have their competency assessed. The registered person must ensure that controlled drugs are stored in a controlled drugs cabinet and records maintained in a controlled drugs register. The registered person must ensure that there are written guidelines/protocol for staff to follow giving clear unambiguous guidance as to when the PRN medication should be administered. The registered person must ensure that 17 Priory Grove is redecorated and worn carpets and furniture replaced and that the decorating planned for 33-35 Priory Grove is completed. DS0000064809.V279295.R01.S.doc Timescale for action 18/01/06 2 YA20 18 (i) 31/03/06 3 YA20 13 (2) 18/01/06 4 YA20 13 (2) 18/01/06 5 YA24 23 30/04/06 Coxwold and Priory Version 5.1 Page 27 6 YA35 18 (i) 7 8 YA35 YA35 18 (i) 18 (i) 9 YA36 18 (2) 10 11 YA35 YA40 18 (i) 24 12 YA42 23 The registered person must ensure that a training plan is developed for the staff team in the home. The registered person must ensure that all staff have an individual training profile The registered person must ensure that all new staff receive induction training that meets LDAF standards The registered person must ensure that all staff receive formal supervision at least 6 times per year, to include the manager. The registered person must ensure that all staff are up to date with mandatory training. The registered person must ensure that Avocets policies and procedures are updated and amended in line with legislation and best practice guidance. The registered person must ensure that certificates are obtained for the electrical hard wiring and gas safety.(9 and 9a Coxwold grove only) 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/01/06 18/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations The registered person should ensure that service users care files are tidied up and possibly reduced into a manageable number of files. All individual plans, behaviour management guidelines and records should be signed and dated and presented in a legible way. The registered person should ensure that the registered manager completes his NVQ level 4 and registered managers Award by 31/03/06 DS0000064809.V279295.R01.S.doc Version 5.1 Page 28 2 YA37 Coxwold and Priory Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Coxwold and Priory DS0000064809.V279295.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!