Inspection on 20/05/05 for Dalvington

This inspection was carried out on 20th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 but made no statutory requirements on the home.

Other inspections for this house

Dalvington 27/07/07

Dalvington 03/07/06

Dalvington 16/12/05

Dalvington 06/12/04

Dalvington 16/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Dalvington 146 Lower Howsell Road Malvern Worcestershire WR14 1DL Lead Inspector Penny Wells Unannounced 20 May 2005 12:00 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 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 Stationary 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. Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Dalvington Address 146 Lower Howsell Road Malvern Worcestershire WR14 1DL 01886 833424 01886 833684 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Elizabeth Fitzroy Support Mrs Susan Jane Vials Care Home 15 Category(ies) of LD Learning Disablity registration, with number of places Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: In addition to those referred to on the previous page, the following condition applies: 1. This service is primarily for people with a learning disability but may accommodate people who also have an additional physical disability. Date of last inspection 6 December 2004 Brief Description of the Service: The registered provider of this home is the charity ‘Elizabeth Fitzroy Support’. A service is offered to a maximum of fifteen adults between the age of 18 years and 65 years with learning disabilities and physical needs. Accommodation is divided into three units. Dalvington is the main unit. All facilities there are on the ground floor and seven people with moderate to heavy dependency needs can be accommodated. The Willows is a first floor flat within Dalvington that can accommodate two people with minimal care needs and good mobility. The Oaks is a separate and can accommodate six people who are less dependent than those in Dalvington and more dependent than those in The Willows. The entire complex is known as Dalvington and is registered as one establishment called Dalvington. Mrs Vials is the registered manager with responsibility for the whole complex. There is an area manager who visits the home on behalf of the registered provider. Mr Neil Taggart, the Director of Operations, is the responsible individual for the registered provider Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection that took place during the day of 16th May 2005. Neither of the inspectors had visited this home previously and spent time preparing for the inspection, four hours at the home and reading information about the home. The majority of the service users in Dalvington unit were at home whilst other service users were out on trips or activities. The service users at home were being supported by three members of staff and appeared well, settled and contented. The focus of the inspection was getting to know the service, meeting with the service users in the Dalvington unit, discussing the service and proposed upgrading of the houses with the manager. The inspectors appreciated the co-operation and time of the service users, manager and staff. What the service does well: The home is an established service for fifteen service users in three units – Dalvington (7), The Oaks (6) and The Willows (2). The service provides a permanent home for fifteen service users who have differing needs and disabilities. The atmosphere is relaxed, caring and safe. The home has an experienced, settled staff team, competently led by the manager. They know the service users and make sure each person is well cared for. The comment cards received and the service users spoken with, all said they felt safe, the staff treated them well and their privacy was respected. The majority liked living at the home, felt well cared for and knew who to speak to if they are unhappy. Comment cards were also received from relatives (8) who, on the whole, were positive about the service, also a positive card from a professional person who knows the home. The relatives who were able to visit the home felt welcomed and informed. Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 Page 6 What has improved since the last inspection? 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. Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 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 standard(s) EVIDENCE: These standards were not fully assessed on this occasion. There had been no new admissions since the last inspection in December 2004. The statement of purpose and service user guide were being reviewed and revised copies should be sent to CSCI. Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 Detailed information was kept to ensure that the service users assessed needs and goals were known to the staff and consistent care was provided. Service users were encouraged to make decisions about their daily routines EVIDENCE: Detailed information about the service users living in Dalvinton unit was available in various files. The manager identified that having reviewed the files of a service user who was being discharged to another home, that all service users files needed to be reviewed. This was endorsed by the inspectors who considered the main files bulky and difficult to audit/cross reference - old information needed to be archived and then the current information filed clearly in sections, with an appropriate index. It was pleasing to note that daily records were kept of activities for individual service users on the days they were at home and not attending a day centre. See comments under NMS 17 & 19 with regard health care needs. Six monthly reviews were due. The format used for reviews needed to be in more suitable formats for the individual service users. Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 Page 10 The manager and staff had identified that a service user’s placement needed reviewing and were waiting on the placing authority to respond. The manager and staff had also supported another service user in moving on. Risk assessments were suitably completed for the two service users whose files were viewed. Risk assessments were kept in the activity file with daily logs. Staff support service users in making decisions about their individual routines. The service users now had personal bank accounts, which they could access with support from staff. The manager was appointee the majority of the service users and this needs to be reviewed. Five of the service users attended an advocacy group arranged by the organisation, which met bi-monthly. In the home advocacy for other service users was being considered. Staff were also introducing two programmes to encourage service users to speak for themselves and to be heard - ‘I’m talking – are you listening?’ & ‘From the inside looking out’. Residents meetings take place in the units. In the comment cards received on behalf of 13 of the service users, 5 of the service users replied that sometimes they would like to be more involved in the decision making within the home. 11 felt well cared for and two responded that ‘sometimes’. Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12-17 The service users were supported to participate in activities in and out of the home and had opportunities for personal development. Their rights and individual preferences were respected. The service users were offered varied meals and snacks, according to their individual dietary needs. The records to evidence this needed more detail. EVIDENCE: Personal development was being encouraged with some service users and two were living in a separate flat supported by staff. The communication team had been involved in setting up an assessment format for daily living skills, care & support. Some service users were given 1:1 support to undertake household tasks such as cooking, cleaning and washing of clothes. All the service users had day placements, locally, on some days of the weekdays. On days that service users were not attending their day placements or college, activities were arranged by activity support workers, who were employed to work in each unit. Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 Page 12 On the day of the visit, the service users in Dalvington were at home. The focus appeared to be on a service users who was leaving and other service users did not appear to engaged in activities. Two service users had been out with staff to purchase presents for the service user who was leaving and some were going out that evening with this person. The Oaks service users were out on a group visit and The Willows service users were also out, one shopping and one a day centre. The home had 4 vehicles for taking service users out. Discussions were taking place about holidays. A service user had enjoyed previous holidays and had photos of these holidays. He also confirmed that he is able to go to church. A service user confirmed that his friends and family visit him. Contact with friends and families was encouraged and voluntary visitors had been arranged for two service users without families in contact. The daily routines were flexible respecting each service user’s preferences and supporting individuals to attend their day centres or college in the week. Service users confirmed that they could choose whether they sat quietly in their bedrooms or in a communal area. A service user explained how he was contented with his lifestyle and felt supported by staff. In the home there were a variety of activities –televisions, games, music, a sensory room, adapted computer and large garden. There was a sensory garden but this was overgrown and needed attention. The comment cards indicated that 11 of the service users felt the activities were suitable and the 2 more independent service users felt they were not. It was apparent from the records that the service users food (and drink) likes and dislikes were known, the service users eating and drinking skills had been assessed and if a service user was not eating, the situation was monitored. Staff could offer an alternative meal from the food supplies in the home. It was reassuring to note that for one individual, food intake was being recorded. However it was of concern that there was not an action plan for a service user whose records indicated that there had been a loss of weight. If service users have been assessed as needing to be weighed regularly, this should be recorded monthly and an action plan compiled if there is a weight/dietary needs problem. There was duplication of the records of ‘food provided’ in service users’ diaries and on menu sheets. This needed to be streamlined so that one, detailed Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 Page 13 record of food provide was being kept which included fresh vegetables, fruit, choice of sandwich fillings. The Oaks had food cards to assist service users with choosing their meals. In the Willows, the service users were involved in preparing their food. Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 The service users were receiving appropriate support with their personal and health care needs. Relevant records were in place to evidence this although in some aspects these records could be developed. EVIDENCE: The service users personal care needs were recorded to ensure that they were offered consistent support in the manner they prefer. Service users could be assisted by a support worker of the same gender. Each service user had a keyworker for individual support such as clothes shopping. Both private and community physiotherapy services are accessed and on the day of the visit a service user was having a physiotherapy session. A senior community physiotherapist has responded that many of the service users would benefit from in-house physiotherapy and that the community service cannot routinely provide this input. This was subsequently discussed with the manager who advised that a physiotherapist did visit the home to see service users who needed input and that this was an individual, private arrangement. The funding for this varied and was being reviewed by the organisation. The community physiotherapists continued to visit to assess and advise. Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 Page 15 Risk assessments for moving and handling, and using a wheelchair were in place to ensure that service users were transferred safely and respecting their preferences. The home had appropriate aids and equipment. The service users’ health care needs, both physical and emotional were also recorded in their plans and professional advice sought at an early stage if a problem arose. This was evident on the day of the inspection with a physiotherapist and speech language therapist visiting the home. Also service users are supported when attending doctor’s appointments and check ups. A form for recording healthcare appointments and outcomes would be easier to follow than searching files for this information or health action plans could be introduced. The manager was given information about the Worcestershire Health Action Plans. Records of accidents were being kept but needed filing appropriately. It was said that there was a quarterly audit. The pharmacist inspector visited the home to view the medication system on 09.06.05 following a medication error. This error had been thoroughly investigated in-house and details sent to CSCI. The pharmacist inspector has sent a separate report to the manager about the medication system and the three requirements have been included at the end of this report. The service users’ consent to medication being administered had not been obtained (previous requirement) because few of the service users would be able to sign their consent. It was suggested that the matter was discussed with their next of kin or doctor, if a multi disciplinary decision could not be obtained. A controlled drugs cupboard and register had been purchased (previous recommendation) but not in use, as not yet needed. The cupboard was to be installed when the medication room in Dalvington unit is upgraded. Standard 21 was not assessed fully but it was pleasing to hear that the local Communication team had provided the service with a book on Death and Dying for the service users in a suitable format. Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 There was a suitable procedure in the home to explain how service users and their representatives could complain. Most service users knew who to speak to if unhappy. Staff observed, listened and responded to the service users. EVIDENCE: There was a complaints procedure in suitable formats for the service users which the local Communication Team had set up. It was discussed at resident meetings and available on video, tape and CD. The service had a book to record any complaints received but there were no entries this year. However some service users had made a complaint and this should have been entered. The manager explained how she had dealt with the complaint in an appropriate, sensitive manner. The comment cards received indicated that the majority of service users knew who to speak to if they were unhappy and 2 did not know. The service users all commented that they safe. 7 of the 8 relatives who responded indicated that they were aware of the complaints procedure but had not needed to use it. Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 The houses were homely, comfortable and clean with each service user having a single bedroom. The service users and staff would benefit from some of the communal facilities and equipment in the units being upgraded as previously identified. EVIDENCE: The service is located in a residential part of Malvern with shops and amenities nearby. Accommodation is divided into three units. Dalvington is the main unit. All facilities there are on the ground floor and seven people with moderate to heavy dependency needs can be accommodated. The Willows is a first floor flat within Dalvington that can accommodate two people with minimal care needs and good mobility. The Oaks is a separate bungalow and can accommodate six people who are less dependent than those in Dalvington and more dependent than those in The Willows. All the units have separate communal rooms lounge, dining room, kitchen, bathroom(s) and toilet(s). Each service user has their own single bedroom with wash basin. Service users have been encouraged to personalize their Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 Page 18 bedrooms and choose their own décor. The bedrooms in Dalvington and The Willows had suitable bedroom door locks but not the bedrooms in The Oaks. The kitchens in Dalvington and The Oaks had been refurbished. The units were homely, clean and comfortable. However it had previously been identified that other parts of the home needed upgrading – toilets, bathrooms, laundry, sluice facilities and storage space (see previous reports for details). The service provider was required in June 2004 to submit a programme for upgrading to the CSCI by 01.12.04 but this timescale was revised to 31.03.05, with all the work to be carried out by 31.03.06. A meeting took place at Dalvington with an inspector to discuss how this could be achieved in the units. A list of the identified work required to be done was submitted to the CSCI on 19.05.05 but did not include timescales. At this visit the manager explained that the upgrading work could not begin until planning permission had been obtained for a temporary building to be erected in the garden for staff facilities and storage. Quotes were being obtained for the upgrading work. It was of concern that this work was not further ahead so that it can be completed within the agreed and required timescale of 31.03.06. Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35 The service users were supported and cared for by experienced, trained and stable staff group. EVIDENCE: Each unit has it’s own staff group led by an assistant manager with support workers, activity support workers and night staff. The service has an administrator and maintenance person. Rotas, training and staff details were submitted which indicated that the service users were supported by experienced, skilled, trained staff whom had Criminal Records Bureau checks. Some staff had worked at the home for many years and knew the service users well. Other staff were new and welcomed by the manager. Staffing levels were appropriate and allowed for service users to have the choice of being taken out in groups or to stay in. 1:1 support could be arranged for specific activities. 4 relatives who visited commented that there sufficient staff on duty. However another relative commented that staffing levels were insufficient on Sundays when all the service users are at home and a sixth relative responded ’no’. Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 Page 20 The home has it’s own relief workers. On occasions when agency workers have to be used, workers are requested who know the service, if possible. The service had benefited from training and support from the local Communication Team so that staff can communicate in different ways with the service users. A service user had a photo board a liberator photo album. The team consists of staff of both genders which reflects the service user group. 38 of the staff have an NVQ in care, level 2 or 3. The service need to have 50 of the staff having completed this training by 31.12.05. New staff undertake the Learning Disability Award Framework (LDAF) induction and foundation course. See NMS 42 re training in safe work practices. This information was provided by the manager and at the next visit, time would be spent discussing these matters with the staff. Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,40,41,42 The service users were benefiting from a well managed home where service users best interests were foremost. EVIDENCE: The return of the experienced, qualified manager to the service was welcomed. The home were keeping appropriate records and had relevant policies and procedures for ensuring the smooth running of the service and safeguarding the rights and interests of the service users. If a record, policy or procedure needed reviewing, this has been outlined in the relevant section of this report. One set of parents who were unable to visit commented that they would like to be kept informed of their relatives progress. It was of concern that monthly reports, from the organisation’s representative visiting the home, were still not being sent to CSCI (previous requirement). Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 Page 22 The standard on Safe Working Practices is wide ranging and was not fully assessed on this occasion therefore it was not scored. However the following was noted: • Staff had undertaken training in safe working practices – basic food hygiene, moving and handling, first aid, health and safety. The majority of staff had a first aid certificate. Consideration should be given to risk assessing whether this was adequate or whether there needed to be qualified first aider (a four day course) on duty at all times. • Training in infection control was being sought. • The gas boilers and cookers had had an annual service. • The home had a certificate of electrical safety. • Regular checks of the fire safety equipment were carried out. The staff had received some fire training/drills but there needed to be a clearer record to indicate that staff were receiving in-house fire safety training quarterly. The last fire drill had taken place in September 2004 and the manager arranged for a fire drill, the week after this visit. Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score x x 3 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Dalvington Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 x x 3 3 x x E52 S18646 Dalvington V227597 200505.doc Version 1.30 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 17 Regulation 17 Timescale for action The record of food provided must 30.09.05 be detailed to indicate that it is nutritional, varied and balanced for each service user. Service users nutritional needs 30.09.05 and weights must be regularly reviewed and when concerns are identified, an action plan introduced. (timescale of 01.01.05 not met) The registered person must Immediate ensure that the records for and documenting the administration ongoing of medication are accurate and appropriate codes used when necessary. The registered person must 31.07.05 ensure that all prescriptions are seen and checked before going to the pharmacy for dispensing. The use of labels from the Immediate pharmacy must not be used and and attached to the MAR chart due to ongoing the increased potential of error. The premises must be suitable 31.03.06 for the purpose of achieving the aims and objectives of the home. Specifically, sufficient toilets and bathrooms must be provided to meet the individual needs of service users and the needs of Version 1.30 Page 25 Requirement 2. 17,19 12,14,15, 17 3. 20 13 4. 20 13 5. 20 13 6. 24,26,27, 29,30 23 Dalvington E52 S18646 Dalvington V227597 200505.doc 7. 26 41 staff; sufficient storage must be provided to enable the safe keeping of large items of equipment and suitable laundry and sluice facilities must be provided in both buildings. (timescale of 30.06.05 not met) Copies of reports generated in compliance with Regulation 26 must be sent each month to the Commission for Social Care Inspection. (timescale of 01.01.05 not met) 31.08.05 and ongoing RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard 1 6 6 19 32,35 Good Practice Recommendations Copies of the revised Statement of Purpose and Service User Guide should be sent to the CSCI. The service user plans/files should be reviewed. The service user plans should be reviewed and the review format be in suitable formats for the service users. Consideration should be given to introducing the Worcestershire Health Action plans or a form for quick reference of healthcare appointments and the outcomes. 50 of the staff should have achieved a NVQ in care level 2 by 31.12.05 Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 Page 26 Commission for Social Care Inspection The Coach House John Comyn Drive, Perdiswell Park Droitwich Road Worcester WR3 7NW 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 Dalvington E52 S18646 Dalvington V227597 200505.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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