Inspection on 18/10/06 for Davids Close (2)

This inspection was carried out on 18th October 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Davids Close (2) 12/05/06

Davids Close (2) 05/10/05

Davids Close (2) 03/05/05

Davids Close (2) 01/12/04

Davids Close (2) 20/10/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Davids Close (2) Werrington Peterborough PE4 5AN Lead Inspector Nicky Hone Key Unannounced Inspection 18th October 2006 11:30 Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Davids Close (2) Address Werrington Peterborough PE4 5AN 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) 01733 707774 F/P 01733 707774 Mr Alan George Atchison Mrs Tracie Ann Green Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th May 2006 Brief Description of the Service: Originally a large, detached private house, set in its own grounds, 2 David’s Close became a home for people with learning disabilities in 1995. Some recent alterations have taken place and all seven service users now have single rooms. There are five single bedrooms and a bathroom on the first floor, and two single rooms, a shower room, two lounges, dining room, kitchen and laundry on the ground floor, as well as an office/sleeping-in room and staff shower room. Two of the bedrooms have ensuite showers. The gardens include a wooded area along the rear fence and there is a fully enclosed outdoor swimming pool, which is no longer used. Located in a quiet cul-de-sac on the outskirts of Werrington, the home is within a ten minute walk of local amenities, and is three miles from the centre of the cathedral city of Peterborough with its wide range of shops and leisure facilities. The planning permission granted by Peterborough City Council also includes an extension to the rear of the house which would increase the number of bedrooms. The provider has decided not to start this work yet. The fees for the places at 2 David’s Close range from £522.68 to £577.71 per week. Inspection reports are available on request from the manager. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit to 2 David’s Close by two inspectors, Nicky Hone and Joanne Pawson. All seven service users were at home at different times during the inspection and several of them spoke to us. We spent over three hours at the home, talking with service users, staff and the manager, looking round the house, and checking records. Since the last inspection the acting manager, Tracie Green, has been registered by the CSCI as the manager. We were pleased that Ms Green is still very enthusiastic about what she wants to improve at the home, although she was feeling somewhat frustrated that she has not been able to introduce improvements as quickly as she wanted to. What the service does well: Service users who spoke with us indicated that they are happy living at 2 David’s Close. One person told us that he has support each week to do things he wants to do, such as bowling, as he has decided he does not want to go to a day service. Service users and staff said they like the new manager and had confidence that she will continue to manage the home well. The home has a complaints procedure and service users who spoke to us said they would be able to talk to the manager or staff if they had any worries. Staff have had training in Protection of Vulnerable Adults so they know how to recognise and report abuse. Risk assessments have been carried out around activities and issues in the house such as the upstairs balcony, and action taken to lessen any identified risks. Service users know that written information about them is kept securely. Friends and family are welcomed at 2 David’s Close and service users assist with the planning of meals. Service users are supported to see health professionals such as doctor, dentist and so on when they need to, and staff administer medicines in a satisfactory way. Generally, the home is decorated well and was clean on the day of the inspection. Some of the bedrooms have been decorated and have new carpets and furniture. Toilets and bathrooms meet the needs of the service users, and the lounge and dining areas are comfortably furnished. The gardens were reasonably well maintained for the time of year. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: We were disappointed that this inspection has resulted in nine new requirements being made, including two immediate requirements that we left at the home during the inspection. This report therefore has a total of eleven requirements, which includes two carried forward from the last inspection as they had only been partly met. The home’s Statement of Purpose and Service User Guide need to be updated and a copy sent to the CSCI. Although there is some improvement in care plans, there is still a lot of work to do before they are useful working documents. The way the care plans are written should be changed so that service users’ strengths and abilities are focussed on, rather than describing only what people need help with. It is not clear from the care plans what support with personal care each person prefers to have. Service users are not offered enough leisure activities, and those that are offered do not appear to be based on what each individual has said they would like to do. Staff said this is because there are not enough staff on duty. Service users’ meetings do not take place so service users do not have the opportunity to formally give their views about the way the home should be run. The hallway of the home has not been decorated and one bedroom smells of stale urine. Staff have not received adequate training in fire safety. Tests of the fire alarm system have not been done every week as required, and chemicals were not stored securely in the way the risk assessment said they should be. The manager was given an immediate requirement notice regarding these two matters. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide are not as up to date as they should be so that readers have current information. EVIDENCE: The home has a statement of purpose and service user guide. The manager is updating these so that details are included to show that she is registered as the manager. All the people who live at 2 David’s Close have been at the home for many years, therefore there are no assessments of needs for new service users to check against this standard. The home has a policy and procedure on admissions which includes the requirement to have a full assessment before a new service user can be offered a place. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments are being reviewed and updated so that staff have the information to ensure service users are supported in the way they prefer. EVIDENCE: Care plans were still being reviewed and re-written. We looked at the care plans for two service users and were pleased that in some ways these are developing, and have improved since the inspection in May. However, we were disappointed that the support plans were still not as personalised as they could be, and that some parts are written in a very negative way. This meant that people’s disabilities and things they are unable to do are highlighted, rather than looking at, and building on, people’s strengths. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 11 It was good to see that reviews of care are taking place. However, the evidence on one of the files indicated that care plans are not updated following the review. In this person’s plan, dated 18/06/06, the review on 27/07/06 referred to a change in morning routine, and daily records noted that “X has been coming down most mornings to prepare own breakfast.” However, the ‘daily support routine’ in the care plan for this person stated “I have breakfast in bed between 7 – 8 a.m.” The manager has introduced some very good picture boards for the service users so that they know, for example which staff will be on duty during the day, and who will be sleeping in at night. Each service user has their own board with their photograph on. The boards show that person’s daily timetable. This is an excellent development and the manager said it will be noted in the care plans when they are next reviewed. We agreed with the manager that we will extend the timescale, for the final time, for the requirement regarding care plans made following the last inspection to be met. We saw some risk assessments on the files we looked at. These are being developed alongside the care plans: the manager told us she has completed risk assessments for everything she has identified as a risk in the house. She is trying to find a risk assessment course so that she is sure she has the knowledge to identify and minimise any risks. Service users told us that they have chores to do around the house, which staff support them with if needed. One service user told us that he helps the manager to do the shopping and go to the bank each week. Formal service users’ meetings are not held, but informal discussions take place and service users are gradually becoming more involved in the running of the home. Service users’ files are kept in a locked cupboard so service users know that information written about them, including confidential information, is secure. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Records show that service users are not given enough opportunities to take part in activities of their choice. EVIDENCE: The inspection we carried out in May 2006 showed evidence that service users were being supported to develop their independence. One of the ways this was happening was that each person had two weekly ‘tasks’ to work at. For example, keeping the bedroom tidy, cleaning teeth twice daily, putting dirty clothes in the laundry and so on. At today’s inspection we saw that each person still has two weekly tasks to work on. However, we were disappointed that we found nothing to show that Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 13 any evaluation has been done to monitor the person’s progress, and how the skills that people have been developing have been maintained and built on. However, we were very pleased to see that all the service users went to the kitchen at lunch time and were supported to get their own lunch. Clearly this has become part of the usual daily routine, and service users were clearly satisfied with their achievements in this area. One service user had been to his weekly “social communication” course on the morning of the inspection. We were thrilled to see how much this has helped in developing his self-confidence as he started a conversation with us, which has not happened before. He told us he was going to a ‘talking group’ in the afternoon. One person told us that he has support each week to do things he wants to do, such as bowling, as he has decided he does not want to go to a day service. Service users are supported in whatever way they wish to maintain contact with family and friends. All the service users who wanted to went on holiday this year. The manager said that the holidays had been arranged at rather short notice, so everyone had a holiday in England. Three people chose to go to a caravan at Heacham (in two groups), and four people chose to go to a caravan at Kessingland (again in two groups). We hope that the service user who told us at the last inspection that he wanted to go to Portugal, might get his wish next year. We looked at the records of the activities that had been done in the first 18 days of October (12 evenings and 3 weekends) for two service users. Service users’ daytime activities are not recorded on this record: this record shows what people have done in the evenings and at weekends. We had some concern about the number of activities that are offered to the service users. Although we accept that not everyone wants to be out and about, or doing a structured activity, all the time, from the records we saw we are of the opinion that there are not enough activities being offered to the service users at 2 David’s Close, and little evidence that what is offered is based on the individual’s own choice. For example, it is clear that on one Saturday, cooking was offered as the activity: both people whose files we looked at “did not want to do cooking”. A record had been made on each of the 18 days in October on the two files we looked at. One showed that the person had been for “a ride in the mini-bus before tea” on one day, and a “picnic out in the park” on another day. On one Saturday it was recorded “refused to take part in cooking”. The only other activity recorded for the 18 days showed that the person had chosen to watch Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 14 TV in their bedroom. The second person had undertaken five activities over the 18 days, including two “out with parents”. Service users have a sandwich lunch during the week and a main meal in the evenings. Staff have realised that service users will be able to make a more informed choice about the meals they want to eat if they see photographs, so these are being collected and laminated, which is good. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ healthcare needs are met and generally staff administer medication safely. EVIDENCE: Further development of the care plans will ensure that service users’ preferences in the way they are supported for personal care will be written down, with evidence that service users have been able to make their preferences known. There was evidence on the files we looked at that service users’ health needs are met. Each person’s weight is recorded every month and appointments are made for people to see the GP, nurse, chiropodist, dentist, optician and so on when they need to. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 16 We looked at the records staff keep when they give service users their medicines. The records were generally quite satisfactory: there were a couple of gaps where staff had not signed to show that a medicine had been given, and one staff member uses the wrong code when service users refuse their medicine. The manager said she will get this sorted out. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that any concerns they have will be listened to and that staff are trained to recognise and report abuse. EVIDENCE: The home has a complaints book, but no complaints have been received. The complaints procedure is on display in the home, and the service users we spoke with were confident that they could speak to the manager or one of the staff if they were not happy about anything. The manager told us that all staff have received Protection of Vulnerable Adults training. The home has a procedure, in line with Peterborough’s procedure, for reporting incidents of abuse. Some of the service users’ weekly personal allowance is kept for them in the safe. Whenever money goes into or out of each person’s tin, it is recorded. The records we saw were accurate and we noted that the two service users’ records show that the service users do not pay for things which should be paid for by the home. All staff now have access to this money so that service users are able to get some money at any time if they want it. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally the house and gardens are well maintained so that service users have a comfortable, clean and homely place to live in. EVIDENCE: We had a look round the home. We were disappointed when we entered the house to see that the entrance hall has not been decorated. There were repaired areas of white plaster on the green paintwork, and loose wires from an old fire panel that has been removed: these were seen at the inspection in May 2006. The wall opposite the door is full of certificates and information, which does not give a very homely first impression. The manager agreed to think about displaying the documents somewhere else. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 19 Most of the house is pleasantly decorated, comfortably furnished and kept clean. Some decorating has been done since the last inspection, and some of the bedroom carpets have been replaced. There was a strong smell of stale urine in one bedroom. The manager said she is planning to replace some of the carpet in this room with washable flooring. In the kitchen there is a large notice board which had lots of information pinned to it, including information for staff such as a cleaning rota and records of water temperatures. We suggested that as the home now has an office/staff room, staff information should go in there. The gardens around the home are gradually being tidied up and made so that there is less maintenance. For example, a fence has been erected in the back garden, to divide the area at the back where trees grow, with the lawned area near the house. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know can be confident that staff receive adequate training and are well-supervised, although there are not always enough staff on duty to meet their needs. EVIDENCE: The staff rota showed that two staff are on duty at all times, plus the manager when she is working. We were concerned that this is not enough, especially at weekends, for any of the service users to pursue individual activities. The manager told us that staffing is being increased on a Wednesday evening so that any service users who want to can go to the Breakaway Club. Staff said that more staff are needed so they can do more activities with the service users. The manager also said she is discussing the fees paid for people’s care, with the local authority, to make sure there is sufficient funding to meet service users’ needs. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 21 We looked at the personnel file of one new member of staff. All the documents required by the regulations were present, including two written references and evidence that a Criminal Records Bureau and POVA check had been undertaken before the person started work. Staff told us that they have done most of the mandatory training (first aid, fire safety, moving and handling, food hygiene). Infection control training is being given to staff at several sessions staggered through this year. Four staff have a National Vocational Qualification in care: one staff member does not want to undertake this training. The manager told us that all staff are now receiving regular supervision, which for now she is doing herself. Staff also told us they receive regular supervision from the manager. Staff said the manager is very supportive, and is willing to listen to ideas. They told us that staff meetings are held every couple of months. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management of this home is improving so service users can begin to be confident that the home is run in their best interests. EVIDENCE: Since the last inspection Tracie Green has been registered as the manager of the home. Evidence gained at the inspection, and observation on the day, showed that she gets on well with the service users and the staff, and that there have been improvements in the service offered. Ms Green is aware that there is still a lot of work to do to make sure the service offered is as good as Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 23 possible. Service users and staff spoken with said they are pleased she is managing the home. A quality assurance system, based on the views of service users, relatives and other people involved with the home, is being developed. Survey forms have been sent out. The owner carries out a monthly unannounced visit, (as required by Regulation 26, Care Homes regulations 2001) and writes a report. These reports were available in the office. We checked fire records and noted that six staff had had training in fire safety awareness in February 2005, and 4 staff in April 2006. All staff should receive fire safety awareness training at least twice in every twelve months. Records of the tests of the fire alarm system showed that only one test had been done in September, on16/09/06, and then on 10/10/06 and 17/10/06. The fire authority requires these tests to be carried out weekly. The record showed that tests of the emergency lighting at 2 David’s Close are done monthly. In the laundry room we found various cleaning chemicals in a cupboard without a lock: the manager had completed a risk assessment the day before the inspection about this, recommending that these are kept in a locked cupboard upstairs. Water temperatures are recorded in the kitchen: we saw that action had been taken when the temperature was too hot, and we recommended that the temperatures are also taken in bathrooms. If the temperature comes out of the tap at above 430C, thermostatic valves should be put in place so that service users can safely use baths and showers on their own. The manager contacted the fire safety officer following the inspection in May 2006 and asked his advice about the fire exit at the rear of the house. This exit has been improved by having the garden gate swing open outwards, and the bin is no longer in the way. A risk assessment has been carried out, and recorded, about the first floor balcony. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 3 3 LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 3 3 2 X X 2 X Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA1 Regulation 4 and 5 Requirement The Statement of Purpose and Service User Guide must be updated and a copy sent to the CSCI. Each service user must have an individual plan of care. Once developed the plan must be kept under review. This requirement has been carried forward and the timescale extended again, to give the manager a further opportunity to develop care plans. Service users must be given the opportunity to participate in leisure activities of their choice. Evidence must be available to show that service users receive personal support in the way they prefer. All parts of the home must be reasonably decorated. The entrance hall must be decorated. Timescale for action 31/01/07 2 YA6 15 31/01/07 3 YA14 16(2)(m) and (n) 12(2) and (3) 31/01/07 4 YA18 31/01/07 5 YA24 23 (2)(d) 31/12/06 Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 26 6 7 YA30 YA33 16(2)(k) 18(1)(a) The home must be kept free from offensive odours. The registered person must ensure that an adequate number of staff is employed to meet the needs of the service users. The quality assurance system at the home must continue to be developed. A report of the results of any survey undertaken must be sent to the CSCI and must be made available to service users. All staff must receive suitable training in fire safety awareness. Any staff who have not had this training within the last six months must receive one session within the timescale. 31/12/06 31/01/07 8 YA39 24 31/01/07 9 YA42 23(4)(d) 31/12/06 10 YA42 23(4)(c) Fire safety equipment, including 18/10/06 the fire warning system, must be tested at appropriate intervals. An immediate requirement notice was left at the home about this. Chemicals must be stored safely in accordance with the risk assessment carried out by the home. An immediate requirement notice was left at the home about this. 18/10/06 11 YA42 13(4)(a) Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA24 YA42 Good Practice Recommendations We recommend that the entrance hall is made more homely by displaying the certificates elsewhere. We recommend that water temperature in bathrooms and bedrooms is tested to make sure that the water is not too hot. Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Davids Close (2) DS0000015147.V316663.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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