Inspection on 26/11/07 for Denmark House

This inspection was carried out on 26th November 2007.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Denmark House 21/06/06

Denmark House 05/12/05

Denmark House 08/06/05

Denmark House 17/11/04

Denmark House 15/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Denmark House 36 Denmark Road Gloucester Glos GL1 3JQ Lead Inspector Ms Lynne Bennett Key Unannounced Inspection 26 and 27th November 2007 13.00 th Denmark House DS0000016423.V348135.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 Denmark House DS0000016423.V348135.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. Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Denmark House Address 36 Denmark Road Gloucester Glos GL1 3JQ 01452 383888 F/P 01452 383888 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) www.carehomes.co.uk Cathedral Care (Gloucestershire) Limited Mrs Nicola Anne Shaw Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2006 Brief Description of the Service: 36 Denmark House is a detached Victorian house within walking distance of Gloucester city centre. The home is owned by Cathedral Care (Gloucestershire) Ltd. The home provides accommodation for nine people with a learning disability who may also challenge the service. Some people have autistic spectrum disorders. All people living at the home have single rooms, some with en suite facilities. There are spacious communal areas, and large gardens to the rear of the house. The home has a car and a people carrier at its disposal. People have copies of the Statement of Purpose and Service User Guide. Further copies are available from the office. Fees for the home range from £990 to £1924 per week. An additional charge is made for use of the home’s vehicle. Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This inspection took place in November 2007 and included two visits to the home. The registered manager was present throughout. Surveys were returned from three people living at the home, five relatives and four healthcare professionals. Seven members of staff returned surveys and staff were spoken with during the visits. Time was spent observing the care of people living at the home and talking to them about their lifestyles. The registered manager completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing considerable information about the service and plans for further improvement. A sample of records was looked at including care plans, financial and medication records, staff files, health and safety documents and quality assurance information. What the service does well: What has improved since the last inspection? Improvements to the environment include redecoration of people’s rooms. One person spoken with said they had chosen the colour scheme. Another person said their bathroom was due to be refitted. Hazardous products were being stored securely. Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have access to the information they need enabling them to make a decision about whether they wish to live at the home. A comprehensive assessment of the person’s wishes and needs are taken into consideration before offering them a place. EVIDENCE: The home has a Statement of Purpose and each person has a copy of the Service User Guide with their terms and conditions on their individual files. Not all of these terms and conditions had been completed. The Statement of Purpose and Service User Guide will need to be reviewed to reflect changes to the way in which people will be charged when using the home’s vehicle. Presently they pay a contribution from their Disability Living Allowance. In the future they will be charged each time they use the vehicle at a mileage rate agreed with Commissioners. Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 9 There have been no new admissions to the home since the last inspection. Documents examined for a person who moved into the home in 2005 included a comprehensive assessment by the home, copies of a placing authority assessment and care plan, and minutes of transition meetings with their previous carers. Denmark House DS0000016423.V348135.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 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are involved in decisions about their lives and play an active role in planning the care and support they receive. Risk assessments safeguard people from possible harm. EVIDENCE: Since the last inspection a new care planning format has been introduced. Three people were case tracked which involved looking at their care plans, risk assessments, financial records and medical records. They were observed during the visits and staff were spoken to about the care they provide. Care plans were based on assessments completed by placing authorities. The registered manager confirmed each person was having an annual review. A copy of a review from a placing authority was on one of the files. The others had mistakenly been archived. Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 11 For those people with additional mental health needs it was evident they had regular contact with a Community Psychiatric Nurse. There was evidence that care plans were being regularly monitored and reviewed with changes being noted. People living at the home said they were signing their care plans and were observed discussing them with their key worker. Comments from a healthcare professional included: “day to day care is caring and person centred.” Care plans provided a holistic analysis of people’s needs. Each person had a care plan summary indicating their primary and secondary objectives and the expected outcomes of these. From this individual care plans were put in place. For instance a primary objective for one person was to ensure their safety and wellbeing. Their care plan provided staff with clear guidelines about the support they would require at meal times to ensure they were kept calm. Staff were observed putting this into practice. Care plans were in place in relation to people’s communication needs, indicating their verbal and non-verbal communication skills. Staff were observed following these guidelines giving a person eye to eye contact, speaking in short sentences and taking care not to interrupt the person whilst speaking. Communication boards were in place and one person explained the meaning of the photographs which had been displayed that day. They were observed being supported by staff to change the photographs during the second visit. Some restrictions were in place. These were recorded in care plans with the rationale for this noted. It was evident these were in place to safeguard people from harm. Financial records were examined and found to be satisfactory with evidence of regular auditing. Receipts were numbered and could be cross referenced with expenditure. One person said they had a new bank account which staff were supporting them to use. All people in the home now have individual bank accounts. Risk assessments had been developed from hazards identified in care plans with evidence of regular review. A missing person’s procedure was in place. Most missing person’s forms had photographs of people living at the home but these needed updating. One person did not have a photograph on their form. Denmark House DS0000016423.V348135.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): 12,13,14,15,16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home make choices about their lifestyle, and are supported to develop life skills. They have the opportunity to take part in social, educational and recreational activities and keep in touch with family and friends. People have a nutritional diet and their diverse needs are catered for. EVIDENCE: Each person had an activity schedule which provided an outline of activities within the home and in the local community. People said they enjoy going to college and one person went to a day centre during the second visit. People were also attending the Guildhall for a variety of courses. One person said they regularly use a local gym. Another person was observed being supported to go to a local shop to buy the daily paper. One person was proud that they had a part time job at a nearby garden centre. Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 13 There was evidence in daily notes and the communication book that people have access to activities at home including arts and craft, aromatherapy, music for health, a sensory room, gardening and helping with activities of daily living. People living at the home said they continue to go to a range of social clubs, pubs, cafes and the cinema. One person had been Christmas shopping and another person had been out for a meal. Concerns were expressed by relatives that the number of staff who were drivers might impact on access to transport. Staff indicated that this may occasionally happen but that people were also supported to walk to local facilities and use public transport. People were being supported to maintain close links with family and friends. One person said they love going to visit a friend at a nearby residential home and another person said that their boyfriend visits them regularly. Comments from a relative indicated that staff keep in touch and pass on information as needed. They also “make me welcome when I go to the home”. Another parent said, “They are wonderful. They bring her over by car every other week for a day visit. I am very pleased with this arrangement”. People were observed making decisions about their day to day lives and being involved in the running of the home. People were supported to help clear tables, wash up, bake cakes, do the shopping, clean their rooms and wash their laundry. Two house meetings had been held this year and minutes were recorded. The registered manager said that the home promotes an open atmosphere with requests and concerns being dealt with as they arise. People living at the home were observed having access to the registered manager during the visits and chatting to her about any concerns. The home has a menu plan in place, which staff said reflects the likes and dislikes of people living at the home. Staff said they encourage people to have a healthy diet. During the visits freshly produced meals were provided such as homemade soup and salad and baked potatoes. One person said they had a Chicken Korma for tea that they had enjoyed and others said they liked the takeaways at weekends. Staff confirmed that where there were concerns about the diet of people the relevant professionals would be involved and monitoring records would be kept. Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are being met helping them to stay well. Promoting the safe administration of medication will safeguard people from possible harm. EVIDENCE: Each person had a pen picture in place which described their likes and dislikes. Discussions with staff confirmed their understanding of the needs of the people they support. A wide range of monitoring records were in place which staff were using where appropriate. For example body maps were in place where unexplained bruising had been identified or people had hurt themselves. For the most part these could be linked with accident and incident forms. One person had unexplained bruising to the eye but no incident record had been completed. We (the Commission) would expect to be informed of such an incident under Regulation 37. The registered manager confirmed that any incidents affecting the wellbeing of people living at the home were normally notified to us. Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 15 Robust records were being kept of people’s healthcare appointments providing evidence that people were having access to their doctor, dentist, optician and the local Community Learning Disability Team on a regular basis. Staff were recording the outcomes of appointments. Letters were on file from health care professionals providing staff with guidelines about the support to be given to people living in the home. Concerns were raised by some healthcare professionals about the skills, knowledge and willingness of some staff to implement suggestions they make. Confidence was expressed in senior staff and management who “are always very willing to listen to recommendations and work well to integrate changes into routines.” A recent letter from a healthcare professional indicated that staff had followed their recommendations with positive outcomes for the person. Any changes to care or medication made by health professionals were being recorded in care plans. This is good practice. Medication systems for the administration of medication were examined and found to be satisfactory. Staff were completing training in the Safe Handling of Medication. A monitored dosage system was being used and records completed in line with safe practice. Pots were in place to give medication to people. The registered manager said that medication was not being put into these containers to be given to people later on. The registered manager must make sure that staff give medication directly to each person as it is dispensed. Records were observed being signed after a person had taken their tablets. A medication audit was in place. The temperature of the cupboard in which the medication was kept was not being monitored. Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are confident in the knowledge that any concerns they may express will be listened to and acted upon. Systems are in place that safeguard people from possible harm or abuse. EVIDENCE: The home had a complaints procedure and people had a copy of this on their file. The home has not received any complaints. As mentioned the registered manager stated that concerns were dealt with as they arise and through house meetings. Staff records confirmed that they access safeguarding adults training during their induction. The local safeguarding adults team provided this training. The registered manager had not attended this course or training on the mental capacity act. All staff were completing training in the management of challenging behaviour and use of physical intervention. They confirmed they have access to refresher training. Staff said that physical intervention would be used as a last resort only and had not been used in the home for sometime. Staff said they were confident in the use of diversion and distraction. Observation during the visits confirmed this. Reactive strategies were in place. The registered manager said that after consultation with the Community Learning Disability Team these were being replaced with other guidelines. Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 17 Concerns were raised by some healthcare professionals about the abilities and level of expertise of some staff to meet the complex physical, mental health and social needs of people living at the home. Parents commented that staff “coped extremely well with behavioural difficulties”. Denmark House DS0000016423.V348135.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, 29 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that is safe, clean and well maintained which recognises their diverse needs creating an environment that matches their personal requirements. Specialist equipment is provided to those people who need it. EVIDENCE: The home has a day to day maintenance programme in place as well as long term refurbishment programme. Spacious communal areas were being well maintained with pleasant decoration and good fixtures and fittings. People share a lounge, dining room, sensory room and seating areas in the hallway and on the landing. Gardens to the rear of the home were being well maintained. The registered manager confirmed that individual bedrooms had been redecorated ensuring each person was involved in the choice of colour scheme. Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 19 A new bathroom had been fitted in the first floor bathroom. One person said that they were having a new bathroom fitted and their bedroom redecorated. Windows and the front door were due to be replaced. The registered manager confirmed that when this work has been completed carpets in the landing, stairs and hallway would be refitted. Records confirmed that one person had been assessed by a physiotherapist and occupational therapist and specialist adaptations made to their room and en suite. Specialist equipment had also been provided. At the time of the visits the home was clean and tidy. Staff were completing an open learning course on Infection Control. People were observed using laundry baskets to take laundry through the kitchen to the laundry. This is good practice. Hazardous products were locked securely at the time of the visits. Paper towels and liquid soap had been provided in communal toilets. Denmark House DS0000016423.V348135.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): 32,34 and 35. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are met by a competent staff team, who have access to a mainly satisfactory training programme that needs to ensure staff have knowledge about the diverse needs of people living at the home. Improvements in recruitment and selection procedures will ensure that people are being safeguarded from possible harm. EVIDENCE: The staff team has stabilised over the past twelve months with two new staff starting work at the home. The registered manager stated that a vacancy currently existed for weekend duties and that additional night staff would need to be recruited in the future. Staff spoken with said that morale within the team was good and that staff were supportive of each other. They felt that communication within the home was good and that they had a positive relationship with management. Comments from healthcare professionals and relatives indicated that there had been improvements in the staff team. Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 21 The registered manager confirmed that 15 staff have or were completing a NVQ Award in Health and Social Care. A further two staff were waiting to register for awards. A senior carer had just completed a NVQ Level 4 Award and was taking a Registered Managers Award. Recruitment and selection files were examined for two members of staff. The manager confirmed she had recently attending training in recruitment and selection of staff for the care industry. Each person had an application form which requested a full employment history. One application had gaps in employment history between 1995-1998. There was evidence that gaps between 2002-2004 had been questioned and written onto the application form. The gaps between 1995- 1998 were verified during the inspection and a written record made on the staff file. Two written references had been obtained prior to employment and both staff had started work upon receipt of a satisfactory Criminal Records Bureau check. There was evidence that verbal checks had been made to verity references. This is good practice. A comprehensive training programme had been put in place. Each member of staff was having an induction followed by attendance on the Learning Disability Award Foundation (LDAF). Completion of LDAF ensured that new staff had completed mandatory training including the safeguarding of adults. Additional training in autism and mental health was being provided. Staff had access to information specific about peoples’ individual needs and conditions in their care plans. Comments from some healthcare professionals indicate concerns about the knowledge and skills of some staff working at the home. However comments from other healthcare professionals verify that staff “are keen to increase their skills and knowledge.” The registered manager had been discussing with staff how to ensure their continuing professional development once they had obtained their NVQ Awards. Denmark House DS0000016423.V348135.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): 37,39 and 42. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. Quality assurance systems need to provide evidence that people living at the home and their representatives are being involved in this process. Health and safety systems protect people from possible harm. EVIDENCE: The registered manager has a NVQ Level 4 in Health and Social Care and the Registered Managers Award. She said she was continuing her professional development with further management courses. Staff, relatives and health care professionals spoke highly the positive outcomes for people living at the home since she has been registered manager. She was recently put forward by staff for the Ted Gully’s Managers Award for Gloucestershire and went on to represent Gloucestershire in the National Awards. Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 23 The home has a quality assurance system in place which included audits of medication, finances and health and safety. Unannounced visits to the home by the Responsible Individual were also taking place. The organisation has recently been awarded the Investors in People Award. The registered manager stated that she also keeps letters from parents and uses feedback from people living at the home as part of the quality assurance system. The latter was not being recorded. Health and safety systems were in place with evidence of regular monitoring by staff. Good food hygiene practice was observed. Staff confirmed they had a copy of the Safer Food Better Business folder and had attended Food Hygiene Training. A fire risk assessment had been completed in April 2007. Denmark House DS0000016423.V348135.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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 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 2 X 3 X 3 X X 3 X Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 25 No 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 YA18 Regulation 37 Requirement The Commission must be informed of any incidents affecting the wellbeing of people living at the home. This includes unexplained injuries of a serious nature. Staff must not be appointed without a full employment history. This is to protect people living at the home from possible abuse. Timescale for action 30/12/07 2. YA34 19(1)(c) Sch 2 30/12/07 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. Refer to Standard YA1 YA5 YA9 YA19 Good Practice Recommendations The Statement of Purpose and Service User Guide will need to be amended to reflect planned changes in charges for the use of transport. Terms and conditions should be completed with personal details. Missing person’s details should include a current photograph of each person. Staff should be encouraged to follow guidelines and DS0000016423.V348135.R01.S.doc Version 5.2 Page 26 Denmark House 5. 6. 7. 8. YA20 YA20 YA23 YA39 recommendations of health care professionals. Any handwritten entries should be initialled and countersigned by two members of staff. The temperature of the medication cabinet should be monitored regularly. The manager should attend enhanced training in the safeguarding of adults and mental capacity training. Feedback from people living at the home should be recorded. Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Denmark House DS0000016423.V348135.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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