Inspection on 21/09/08 for Delos Community Ltd, 109 Great Park Street

This inspection was carried out on 21st September 2008.

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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Delos Community Ltd, 109 Great... 04/09/07

Delos Community Ltd, 109 Great... 13/06/06

Delos Community Ltd, 109 Great... 14/02/06

Delos Community Ltd, 109 Great... 01/09/04

Delos Community Ltd, 109 Great... 04/05/04

Delos Community Ltd, 109 Great... 02/03/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

CARE HOME ADULTS 18-65 Delos Community Ltd, 109 Great Park Street 109 Great Park Street Wellingborough Northants NN8 4EA Lead Inspector Ansuya Chudasama Unannounced Inspection 21st September 2008 11:00 Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.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 Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.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. Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Delos Community Ltd, 109 Great Park Street Address 109 Great Park Street Wellingborough Northants NN8 4EA 01933 222532 01933 677881 info@delos.org.uk www.delos.org.uk Delos Community Limited 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) Mr Simon Nicholas John Hardwicke Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may only admit service users aged 18-65 No person falling within the category MD may be admitted to the home unless that person also falls within category LD - I.e. dual disability 4th September 2007 Date of last inspection Brief Description of the Service: 109 Great Park Street is situated in a residential area close to the town centre of Wellingborough. The home is also known as The Frogpond and is one of four registered homes within easy walking distance of each other, supported by a Head Office and Day Centre in separate premises. Further support services are provided within the organisation for those moving on into a more independent lifestyle. The collective facilities are known as the Delos Community where residents are known as members. The home provides personal care and support for up to three members whose primary care need is due to having a learning disability. The environment is that of a family house. Members have their own bedrooms but there are no en-suite facilities. The range of fees at the home is £650-£1723 per week. This fee does not cover the full cost of individual holidays arranged with the home, nor personal toiletries or clothes. Details about the home including the Statement of Purpose and Service Users Guide are available from the Registered Manager and some information is available in user-friendly formats. The most recent inspection report is available through the home or on the Commission for Social Care Inspection website. Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home has one star rating and this means that the people using the service receive an adequate service. We went to the home without telling any one that we were going to visit on the 21st of September 08. We spoke to the staff on duty and a senior member of staff came to help with the inspection. We talked to some of the residents, and looked at information about policies and procedures, which tells the staff how to do things in the home. We looked at the training that staff do to look after the people living in the home. We looked at information about some of the people who live in the home to find out how their needs are being met by the staff. This is called case tracking. We watched how the people and staff living in the home got a long together. The home sent us their Annual Quality Assurance Assessment when we asked for it. This is a document that the home completes to tell us how they are running the home and any improvements they are making. Written comments from two staff and a survey from one of the people living in the home was sent to us. The comments received were very positive about the care being provided by the home. We would like to thank the staff, and the people living in the home for their time in helping with this inspection. What the service does well: Some of the people living in the home say they: • • • • • • • ‘The food is lovely’ ‘Like living here’. They know who to tell if they are unhappy. They go on holiday ‘Like the staff’ Go shopping to buy new clothes ‘Says homely’ DS0000039664.V372596.R02.S.doc Version 5.2 Page 6 Delos Community Ltd, 109 Great Park Street • ‘Visited the home and liked it’ The staff spoken to say: • • • • • That they enjoy working at the home. They attend training to help them meet the needs of the people they look after. They have meetings called supervision with their management to discuss how they are getting on at work and meeting the needs of the people they look after. They help people living in the home to learn skills to help them become more independent They get on well together The Inspectors observed: • • • Staff were talking to the people living in the home in a positive and caring manner. The home was clean and tidy The people living in the home are also encouraged to help with household chores and do as much of their personal care as possible. What has improved since the last inspection? What they could do better: • • • • • • • • • • Ensure that the service users guide has all the information that is needed. Ensure that a medication cupboard is provided that meets the regulation Ensure that staff sign the medication records when giving out medication Ensure that all information needed before a member of staff starts work is obtained Ensuring that volunteers do not work permanent staff hours. Ensure meals are eaten in a relaxing atmosphere Provide a quality assurance system that monitors the views of the people and meets the regulation Ensure the care plans has the information needed to meet the needs of the people being cared for Provide health action plans Provide person centred planning for all the people living in the home. DS0000039664.V372596.R02.S.doc Version 5.2 Page 7 Delos Community Ltd, 109 Great Park Street 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. Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.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 Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.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): 1,2,4,5 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The people living in the home are given information about the home and are able visit and have overnight stays prior to making a decision to stay at the home EVIDENCE: The home has a Statement of Purpose and a Service User guide. The arrangements for dealing with complaints in the service user guide needs to have the information about the time scales of responding to complaints. It also talks about referring information to the board. The guide needs to have the contact name and address and telephone number of the people to contact. Information about the commission for social care inspection and social services needs to be recorded. Information on key contract terms covering admission, occupancy and termination of contract also needs to be included in the guide. The service user guide was in picture and widget format. We spoke to a new person that was admitted to the home who said that they had visited the home with their family. They were also given information Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 Page 10 about the home and had over night stays and liked the place and decided to stay at the home. There was evidence to show that the staff had been involved in the assessment process and had attended meetings prior to the person being admitted to the home. One persons contract was seen and it was signed by them but not dated. It is good practice to ensure that a representative who is able to advocate for the person is also involved in the process of signing a contract. This is to further protect the rights of the people being cared for. The information recorded in the contract about CSCI is incorrect. Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 Page 11 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): 6,7,9,10 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People living in the home have care plans but these needed developing further to ensure that all the information needed is available to guide staff to meet people’s needs. EVIDENCE: All the people living in the home had care plans. One person spoken to had not seen their care plan. Another person spoken to had seen their care plan. One persons care plan was case tracked and information read stated that reviews with the funding authority was taking place. The date the care plan was recorded was in December 07 and stated that the plan should be reviewed in February 08. The care plan had not been reviewed and the date of the day Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 Page 12 the plan is implemented needs to be recorded. The plan needs to include all the information stated in the standard. The plan needs to be recorded in a format that the people using the service can understand. Information recorded in the support plan was not always recorded in the care plan. Also information recorded needs to be explained to state why this was being done. Any goals being worked on also needs to be recorded in the care plan. All documents must be signed and dated and need to state the name of the person completing them. There was evidence seen on the day of the inspection when staff were observed talking to the people living in the home in a positive manner. They were also being involved in what they were doing. They respected the people’s rights when they did not want to get involved in doing any thing. Risk assessments were seen for the person that was being case tracked. However as discussed at the inspection that the risk assessments needed to be individualised and not put them under one risk assessment as the risk were different for each one of the them. It was also discussed that these should be recorded in a format that the people living in the home can understand. The information about the people living in the home was kept in a cupboard locked in the lounge/dinning room. The staff understands issues about confidentiality and had read this information. Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 Page 13 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): 12,13,14,15,16,17 People who use this service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People living in the home are provided with a variety of activities in the home and in the wider community to meet their social needs. EVIDENCE: On the day of the inspection, it was observed that one person living in the home was going out shopping with a member of staff and they were quite excited about this. Another member of staff was observed preparing the Sunday lunch. One of the people living in the home was sitting in the lounge and they explained that they don’t like cooking but said ‘let the staff do it’. One of the people was having a lay in bed. It was observed that the atmosphere was of a relaxed family run home. One person did not want to Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 Page 14 talk to us but stated that they liked staying at the home. Another person living in the home explained that they had two cats and one of them belonged to the other person living in the home. They said they helped feed the cats and looked after them with support from staff. The person stated that they helped with some domestic chores in the home. They said that they went to town sometimes and enjoyed going to the market with staff. The person also kept their room tidy. All the people living in the home said that the staff were ‘very nice’. Two people in the home had scooters and these were kept at a sister home nearby. This was because the home did not have enough storage space to accommodate them at the home. One person’s activity for the week showed that they did a variety of things and the person enjoyed the activities they did. The people living in the home go on holidays with staff and some go on holiday with families. It was also said that the meals at the home were very nice and at lunchtime very positive comments were said about the food eaten. The meal was eaten in a relaxed atmosphere with staff being supportive and talking to the people living in the home. Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.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 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The policies and procedures on administering medication are not always adhered to in order to ensure the people’s needs are met EVIDENCE: There was information in care plan document saying how the personal care needs of the people were being met. One person living in the home said that they bought their own clothes and went shopping with staff. All the people were appropriately dressed. One person’s file looked at showed that there was information about how their health needs were being met. There was information about medical appointments recorded in the file. The home did not have Health Action Plans for individual people living in the home Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 Page 16 The medication in the home is kept in a cupboard, which has files of people living in the home. The cupboard is locked. The medication needs to be stored in a medication cupboard that is attached to the wall and the new medication guidance states that homes need to have a controlled drug cupboard. The temperature of medication cupboard also needs to be taken and records kept of this. The medication charts looked at showed that there were gaps where medication had not been signed and we were not able to tell if the person had their medication or not. The home has changed to the ‘Boots’ medication system. Medication profiles are kept of individual people living in the home. Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.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 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The appropriate agencies are not being informed of incidents that occur in the home in accordance with the requirements of the regulations and local protocols. EVIDENCE: The people living in the home knew how to complain to staff and we were told that the organisation had given them a leaflet on how to make a complaint. The AQAA states that what they could do better is to record ‘low level ‘grumbles’ as they do ‘not currently exit’. However the terminology used should be positive on accepting such comments. The staff spoken to on duty say that they have completed training on safeguarding of vulnerable adults. The staff gave examples of how they would be able to recognise this with the people living in the home. The training records seen also confirmed that staff had received this training. We were informed that no safe guarding referral had been made to the safe guarding team of social services. However information seen in the files showed that people hitting each other had not been reported to the safe guarding team of social services. One person living in the home told us that Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 Page 18 one of the people living in the home had hit them. Regulation 37 notices were also not being sent to the CSCI when incidents/accidents occurred in the home. Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The people live in a homely environment but some of the areas in the home need attention to meet the needs of the people living in the home. EVIDENCE: A tour of the environment showed that the garden needs attention as it’s over grown. Also old furniture needs replacing in the garden with new furniture that meets the needs of the people living in the home. The bathroom and toilet need modernising as it is showing signs of wear and tear the toilet seat in the toilet was also seen to be unsteady. The cupboards in the kitchen are also showing signs of wear and tear, and some of the equipment such as the mop, bucket, and brush, need to be better stored. The kitchen window frames Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 Page 20 needs attention and the lounge furniture also needs replacing or repairing to make it more homely. Discussion about rearranging some of the things in the lounge/dinning room was seen as very positive and good from staff. One of the people living in the home was getting a new wardrobe and a matching chest of drawers. However one person needed a new wardrobe and chest of drawers and two people living in the home need their carpets replacing. The front of the home needs decorating and the bushes need cutting back. Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. The staff work well as a team but the recruitment procedures needs to be robust to ensure people living in the home are protected from potential abuse. EVIDENCE: We were told that the staffing had increased to two staffing since one of the people living in the home needed one to one support. Usually there is one member of staff on duty but when two are required, this is provided. The staff spoken to stated that the staffing levels for the home was ‘fine’ and did not need any extra staff. We found that when a volunteer is working at the home, they sleep in the basement of the homes cellar and do the sleep in duty at the home. The home Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 Page 22 must stop this practice because a volunteer cannot work as a paid member of staff unless they have all the information stated in the recruitment procedures and have the training and experience to undertake the work they are to perform and have a contract. The staff have team meetings every four weeks and it was said that they had supervision on a monthly basis. Training was said to be good and the team leader said that new staff complete the learning disability qualification. Staff felt supported by the team leader. We were given a training record sheet for training to be done for August, September, October, November, and December 08. We were also given a copy of all the training carried out by staff working in the home. It showed that none of the staff had done infection control, six people had done NVQ level 2 or above, four people had done mental health and two of the people had done this in 2002 and in 1991. 4 people had done person centred planning, 6 people did training on fire awareness and one did it in 2004. 6 people had done medication training, 6 people had food hygiene three people had done it in 2004, one in 2005 and one in 2006, five people had done challenging behaviour training. There is no training on autism being undertaken. The day and month of when the training was undertaken needs to be recorded. All staff spoken to say that they like working at the home and work well as a team. Information on three staff files was inspected at the day of the inspection. Evidence showed that all the information was complete for two staff files inspected. However one staff file seen had two references undertaken after they had started employment with the company. Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42, People who use this service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. Service users benefits from a well run home and management is aware of where improvements needs to be made to meet the needs of the people living in the home. EVIDENCE: The staff spoken to stated that they felt supported by management. The manager of the home was not present and the team leader of the home assisted with the inspection. Discussion with the team leader and staff was very positive about the changes that needed to be made in the home. It was Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 Page 24 also discussed that if the home had a computer, the staff would be able to do their care planning and other work on it. Management needs to ensure that monitoring systems are put in place to ensure that all the information needed for staff recruitment is obtained for all staff. Volunteers who work at the home must not work a shift that should be covered by a paid permanent member of staff. One regulation 26 visit dated May 2008 was seen but there were no others found in the home. The date the visit is carried out needs to be recorded. We asked for some of the regulation 26 visits for some of the months of this year to be posted to the CSCI and at the time of writing this inspection but these were not received. We were told that quality assurance was being looked at by the The home were not reporting regulation 37 notification when incidents/accidents were occurring at the home We were told that the manager had completed a fire risk assessment on the 1/5/08. This was not available in the home. It was kept at central office. This information and any information about the home with regard to health and safety must be available at the home. General risk assessments were available and had been done in November 2005. These needed reviewing and the team leader said that these would be completed. The fire officer had visited on the 19th of June 08 and had made 4 requirements. We were told that these were being complied with, and the information was held at central office. The Environmental Health Officer had last visited in July 05. All staff needs to have food hygiene training and those staff who need to update their training after three years. Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 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 2 2 3 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 X 2 X 2 2 X Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 Page 26 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 YA6 Regulation 15 Requirement The care plan must include all the information stated in the standard and describes any restrictions on choice and freedom; the plan should be drawn up with the involvement of the service users representative or an advocate and reviewed on a six monthly basis or sooner. Risk assessments for people living in the home must be individualised to minimise the risk to them. The medication records must be signed by staff to state if the service users have received their medication to ensure that they given the medications that is prescribed for them. All allegations and incidents of abuse must be reported to the Local Authority Safe Guarding team to ensure the safety and protection of service users. Ensure that all the staff receive training in autism, food hygiene, and infection control and other training that is on the list. DS0000039664.V372596.R02.S.doc Timescale for action 30/11/08 2 YA9 13 12/12/08 3 YA20 13 30/10/08 4 YA23 13 30/10/08 5 YA32 18 30/12/08 Delos Community Ltd, 109 Great Park Street Version 5.2 Page 27 6 YA33 18 7 8 YA39 YA39 26 24 9 YA42 37 Volunteers must not work permanent staff hours as they are not protected by a legal contract. The organisation must carry out regulation 26 visits on a monthly basis to monitor the home Introduce quality monitoring assurance procedures as specified by this standard and regulation. Under regulation 37 of the Care Standards Act 2000 the registered provider must inform the Commission for Social Care Inspection in writing, of any serious injury to a service user and any event in the care home that adversely affects the well being or safety of any service user. 30/10/08 30/11/08 30/12/08 30/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team 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 Delos Community Ltd, 109 Great Park Street DS0000039664.V372596.R02.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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