Inspection on 27/01/06 for Downing View

This inspection was carried out on 27th January 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

Downing View 27/01/09

Downing View 28/03/07

Downing View 15/10/05

Downing View 14/01/05

Downing View 25/05/04

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 Downing View 1-3 Loring Road Dunstable Beds LU6 1DZ Lead Inspector Rachel Geary Unannounced Inspection 27th January 2006 16:25 Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Downing View Address 1-3 Loring Road Dunstable Beds LU6 1DZ 01582 604416 01582 670226 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) Bedfordshire County Council Mr Mark Anthony Edmunds Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. No of residents: 2 Gender: Male & Female Age: 18 - 65 years Category: Learning Disability Period of stay: Respite only - up to a maximum of 6 weeks Until re-provision of this service takes place, the premises must be safe, and meet the service users’ individual and collective needs. 15th October 2005 Date of last inspection Brief Description of the Service: Downing View is a respite service located on the outskirts of Dunstable. The accommodation and grounds are owned and maintained by Aldwyck Housing Association, with Bedfordshire County Council providing the staffing and care support. The long-term plan for this service is re-provision. This is because the building does not meet the National Minimum Standards for Younger Adults (18-65) environmental requirements. It is hoped that the service will remain in the local area. The accommodation comprises of a small flat, which is intended to provide respite care for up to 2 adults with learning disabilities at any one time. Stays are limited to a maximum of six weeks. There are two single bedrooms, a shared kitchen, bathroom (with shower facilities only), and living/dining area. The accommodation would not meet the needs of all individuals with a physical disability. Community facilities and shops are a short distance from the home, which is also in easy access of local transport routes. There is ample parking to the front and rear of the property, and there is a small enclosed garden. Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, and took place from 16.25 to 19.15. The inspector met four service users, spoke to staff on duty, observed practice, looked at records, and had a partial tour of the premises. Two service users were staying overnight, one service user had come for tea, and another service user was due to go home, and was waiting to be picked up. After the inspection, written feedback was left for the registered manager of this service, requesting some additional information, which was not found during this inspection. By the time of writing, this had all been received, and has been included in this report. Information provided within the home’s business plan, indicates that there are currently almost 30 service users receiving respite care at Downing View. What the service does well: What has improved since the last inspection? There was evidence of a number of improvements being made. This included some of the previous inspection requirements being addressed. Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 6 The registered manager has once again resumed day-to-day control of the service. Some clear priorities and actions to move the service forward have been highlighted through the quality assurance system, and within the business plan. What they could do better: There are still a number of things that the home could do to improve the service that is provided. The timescales for some of the previous inspection requirements have not been met, and have now expired. To this end, revised timescales have not been given within this report. It is paramount that these are now addressed as a matter of urgency, or the Commission for Social Care Inspection will be minded to take further action in order to bring about compliance, in accordance with the legal responsibilities of the Registered Provider. Care plans and related paperwork need further work to provide sufficient information for staff to meet the holistic needs of service users, and to demonstrate that the service users’ current needs are being met. The results of the home’s quality assurance and monitoring survey included the following suggestions for improving the service: • • • • • • • • • Improving the front and back gardens Providing a bath Having a bigger unit/more bedrooms/more storage space Remedying the muddy paved area at the front of the building and the dripping outlet by the gate Clearing the litter from outside the unit To be able to take service users out more Having more money for service user activities Protective clothing for staff, or a shower screen Having less tea visits Finally, the service must continue to develop paperwork and systems for staff and service users, to make sure that they are meeting legal requirements, and the Government’s standards for services such as Downing View respite service. 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. Downing View DS0000033029.V274923.R01.S.doc Version 5.1 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 Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1. Some useful documentation is available for prospective service users and their families. However, the Service User Guide still contains insufficient information for service users to be clear about the service being provided at Downing View. EVIDENCE: Updated copies of the home’s Statement of Purpose (SoP) and Service User Guide (SUG) were sent to the CSCI following this inspection. Some good attempts had been made to ensure the SUG was user friendly. As previously reported, both documents contained the majority of required information, however both required updating, as some information was inaccurate or missing. For example there were references to the ‘National Care Standards’ and the ‘Care Standards Commission’, which might be confusing to someone unfamiliar with the CSCI. In addition, old NCSC and CSCI registration certificates were on display within the unit. Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Care plans and risk assessments do not enable staff to meet service users’ holistic needs and aspirations. Neither do they adequately promote opportunities for service users to build on their independent living skills. EVIDENCE: Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 10 Examination of one service user’s file showed that the care plan and related risk assessments required updating. This is because they did not contain the most up to date information relating to the individual in question, including their current skill levels. For example, one risk assessment indicated that staff supported the service user with his finances, yet further information set out the service user actually managed his own money. Other inconsistencies related to the person’s daytime activities, and ability to travel independently. Although there was evidence of risk assessments being reviewed regularly, those that were seen contained a lot of non-specific statements. Additional information was available - a ‘pen picture’, which contained some useful information however, some of this was undated or not signed. A number of personal aims had been identified, within the pen picture, and also within the person’s most recent review notes however, these had not been fully incorporated within the care plan. The home had developed a number of systems to help service users to be able to understand information provided by the home, and to be able to make certain decisions. One example, as previously reported, was a document called ‘planning your stay with us’. Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 15. There is evidence that service users have access to a variety of meaningful activities. However, because of deficits with the care planning system, it is not possible to say whether individual preferences are adequately being met. EVIDENCE: Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 12 Due to the nature of the service, the service users’ main educational/occupational needs, are supported by their families/main carers. As previously reported, the home was using a system called ‘planning your stay with us’. The system involves completing a user-friendly chart with each service user on arrival at the unit, covering their preferences with regard to leisure activities and working on independent living skills. No external activities had been planned during this inspection however; there was some evidence that staff had tried to support one service user to go out for a meal earlier in the day (her chosen activity). This had been declined because of bad weather. All service users spent time watching TV or participating in some light domestic cores. One service user appeared quite restless and was observed frequently staring out of the windows, and into the corridor of the adjacent domiciliary care service. Activities recorded for this same service user, since the last CSCI inspection, were as follows: a trip to a local park, a takeaway meal, an outing to buy sweets, a visit to a pub, and participating in meal preparation and clearing up. The service user in question told the inspector that he could not go out that evening because of the behaviours of another service user. Staff denied this, but confirmed that nothing had been planned for that evening. One service user was still waiting to be picked up from his tea visit at the end of this inspection, which would have meant at least one member of staff needing to remain on site. Some boxes were in situ in the living room, which contained various items to enable service users to participate in activities within the unit. There was evidence that staff maintained regular contact with relatives/representatives of service users. Comments and required actions were being recorded, but it was not always clear if these had been acted upon. Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 20. The home has not yet adequately addressed concerns relating to medication administration and training, and the separation of the respite and adjacent domiciliary care services. EVIDENCE: Staff were observed treating service users with respect, and providing appropriate support, in a manner that encouraged service users to maintain their own independence. Due to the nature of the service, the majority of service users’ health needs are supported by their families/main carers. It was previously reported that staff from the adjacent domiciliary care service, were required to support with the administration of medication within the respite unit. This was because the medication policy requires two staff to administer medication, and there are not always two staff on duty within the respite unit. In addition, agency staff had not been trained to administer medication, and were still providing the majority of support. This arrangement was still in place at the time of this inspection, and a member of staff from the adjacent domiciliary care service came in to support with medication during this inspection. Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 14 An operations manager had developed a clear and comprehensive draft policy specific to the respite service which set out that there was an ‘ongoing dialogue between Operations Managers and Agency Managers about the need for agency staff to receive basic medication administration training’, and that ‘agency staff who are requested to administer medications will also be subjected to Beds County Council medication training and a pharmacy session’. A member of staff confirmed this to also be her understanding. The Responsible Individual for this service, Val Leggatt, had previously confirmed that a number of BCC permanent staff were due to start a 21-week distant learning course entitled ‘The Certificate for Safe Handling of Medications’. It was said that in the first instance, permanent staff would support respite medication training, and that there were plans for the agency, Paveys, to use the same training for their staff. Eventually, it is the intention that all respite staff will be trained. Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home has a satisfactory complaints system, and there is evidence that appropriate arrangements are in place for protecting service users from abuse. EVIDENCE: The home’s Service User Guide contained information on how to make a complaint. In addition, a user-friendly version had been developed, and was on display in the entrance hall. A complaints folder had been set up in the office. There was no indication of any complaints being received since the last inspection of this service. The manager provided information after this inspection, which indicated that staff had received training regarding the local multi agency protocol regarding the protection of vulnerable adults in Bedfordshire and Luton. Due to the nature of the service, service users’ finances were being held and maintained by families/representatives and not the home. There were systems for holding small amounts of money during individuals’ stays however, should this be required. Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24. The environment does not adequately meet the environmental requirements of the National Minimum Standards (NMS) for Younger Adults (18-65), although good efforts have been made to provide a homely place to stay. EVIDENCE: Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 17 As previously reported, the respite unit is part of the existing Downing View building which has been ‘made good’ until re-provision of the service takes place. The unit operates in conjunction with Aldwyck Housing Association, who is responsible for the maintenance and upkeep of the building, fabrics and furnishings. The accommodation does not adequately meet the NMS environmental requirements, and would also not meet the needs of all individuals with a physical disability. To this end, the home’s long term plan is reprovision. At the time of this inspection, there were still no definite plans for reprovision to take place. Therefore, in the interim, the CSCI has agreed that the environment must at a minimum, meet the needs of the service users. The home’s conditions of registration have been updated accordingly. The inspector was shown both service user bedrooms. Each room appeared to be equipped with adequate fixtures, furnishings and equipment for the purpose of a respite service. There were no ensuite facilities and no washbasins in bedrooms. Photographs, and pictures drawn by the service users, were on display in the unit, which created a ‘homely’ feel. Hand soap was available in the bathroom on this occasion. At the time of this inspection, the unit’s tumble drier had broken. It was said that staff were using a dryer within the adjacent domiciliary care service whilst this facility was out of action. There was no evidence of this being agreed to by tenants from that service. In addition, some clothes were found that belonged to a service user who had gone home. Staff said that this had probably happened because they were using the facilities in the other service, however, no one was clear how the persons’ inventory could have been signed off as complete, if these items had been missing when packing. Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Continuing inconsistencies in the information held on staff files calls into question the homes commitment to providing suitable staff to meet the needs of service users. EVIDENCE: Apart from the manager, all staffing support was being provided by an external agency – Paveys. The home was using a small core group of staff, and two agency staff were on duty at the time of this inspection. Staff were able to demonstrate a fair understanding of the service users’ needs, and the requirements of the service. A positive rapport was also noted between service users and staff. A draft copy of a job description for the respite manager was provided after this inspection. As previously reported, most of the staff working in the home are agency workers, and following an agreement with the CSCI, personal profiles were being maintained in the home for all staff. Original documentation was being kept on file by the agency. Once again, most profiles contained the required information however; one did not include a recent photograph, and some of the information relating to previous qualifications, was not dated. There was also no evidence that the manager had verified this information. Information relating to the manager was not being held in the home, and was being held Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 19 centrally. The CSCI has recently developed some new guidance, which allows for greater flexibility about the storage of staff vetting records, subject to agreement with the local CSCI office. Once an agreement has been reached, certain records may then be held centrally rather than in the care home. At the time of writing, an agreement had not yet been set up. Copies of individual staff training and development plans were provided after this inspection. There was no plan for the manager. There was evidence that staff were receiving training however, once again, dates were not always recorded for courses that had previously been completed. However, some refresher dates had been identified. The home’s Statement of Purpose sets out that the ‘respite unit provides accommodation for people with a variety of learning disability and health needs i.e. epilepsy and autism’. There was no evidence that all staff had been trained to reflect these needs, and autism was not actually included within the specialist training section on the training and development plans. There was still no evidence that agency staff completed the required LDAF (learning disability award framework) induction programme. In addition, it was also not clear how many of the agency staff had completed a relevant NVQ. The training and development plans recorded a date, but it was not clear if this was the start or completion date. One member of staff confirmed that she had not yet completed an NVQ however; there was a tick against this on her individual training and development plan. Concerns relating to such inconsistencies were also highlighted at the previous inspection of this service. Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 and 43. Generally, this is a well-managed service. The manager is highly competent and consistently demonstrates his commitment and vision for this service. Because of recent temporary management arrangements, there is evidence of limited progress being made in a number of important areas, however; it is anticipated that this will be addressed now that Mr Edmunds has resumed sole charge. The inspector has previously advised that given the increasing numbers of service users, that the part time status of the manager should be kept under review. Findings from this inspection have not changed this view. EVIDENCE: Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 21 It was previously reported that in order to cover maternity leave, the registered manager, Mark Edmunds, had also been temporarily managing the adjacent domiciliary care service. Temporary management arrangements had been made within the respite unit, with Mr Edmunds overseeing this service. At the time of this inspection, Mr Edmunds had resumed sole charge of the respite service. A copy of a letter written by the Responsible Individual for this service, Val Leggatt, highlighted the commitment and hard work provided by Mr Edmunds during this period. The CSCI had only received one report in accordance with regulation 26 of the Care Homes Regulations 2001, since the last inspection of this home. Since the last inspection, there was evidence that the service had compiled the results of questionnaires that had been distributed to staff, service users, and service user representatives, as part of the home’s quality assurance and monitoring process. It was not clear if, or how the results had been shared with the participants. There was also no evidence of the service users’ views being included in the Service User Guide as required. The results included the following suggestions for improving the service: • • • • • • • • • • Providing some seating in the garden Improving the front and back gardens Providing a bath Having a bigger unit/more bedrooms/more storage space Remedying the muddy paved area at the front of the building and the dripping outlet by the gate Clearing the litter from outside the unit To be able to take service users out more Having more money for service user activities Protective clothing for staff, or a shower screen Having less tea visits Some of the good things that people said about the service were as follows: • • • • • • • It is a reliable service There is a good/friendly atmosphere The staff are friendly Good quality staff with good attitudes and knowledge Clean, fresh unit with plenty of daylight – homely (One of the service users) is happy with the unit Good feedback and communication with regard to the management team The results had been updated to say that outside seating had been provided. Otherwise, it was not clear what actions (if any), were being taken to address the other suggested improvements. Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 22 There have been previous inspection concerns regarding the ‘blurring’ of the respite service and adjacent supported living service. There was still some evidence of this, which included medication and laundry arrangements as reported above. In addition, one service user stated that he had gone into the main unit to get some stationary with a member of staff. Previous concerns relating to the safety of the electrics in the unit had been addressed, and there was evidence that all appropriate actions had been taken at the time, to promote the safety and welfare of service users and staff. The manager provided information after this inspection, which indicated that staff had received training with regard to Fire Evacuation in the event of an emergency, and that the home’s fire extinguishers and alarm system had recently been tested. No concerns relating to health and safety were noted during this inspection. The manager provided a copy of the home’s business plan after this inspection. The plan had been updated in January 2006, and contained clear information regarding the key priorities for this unit. These included the following: • • • • • • • • • Developing the service for community living including supported living Reprovision of the service Developing PCP (person centred planning) approaches Updating the medication policy and training Employment of full time (permanent) staff Creating a budget specific to the respite service and further financial training for the manager Further development of the Quality Assurance system Diversity training for staff, and To link with similar services to promote a coordinated approach Timescales were provided for some of the above, but not all. Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 X 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 3 25 X 26 3 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 2 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 2 X 3 X 2 X X 3 3 Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 5 and 6 Requirement Review the Service User Guide to ensure it includes all the information set out in regulation 5 of the Care Homes Regulations 2001, and National Minimum Standard 1 (NMS) for Younger Adults (18-65). [Previous timescale of 31/3/05 not met.] Ensure that care plans include goals aimed at supporting individuals to maximise their independent living skills. Care plans must be reviewed regularly and show evidence of involvement of the service user. [Previous timescales of 30/9/04 and 31/3/05 not met.] Ensure that risk assessments are sufficiently detailed to ensure that all aspects of the service user’s (individual) needs are covered. [Previous timescales of 30/9/04 and 31/3/05 not met.] Ensure that all staff working in the home receives medication training. Ensure that information detailed under schedule 2 and 4 of the DS0000033029.V274923.R01.S.doc Timescale for action 30/11/05 2 YA6 15 30/11/05 3 YA9 13(4)(c) 30/11/05 4 5 YA20 YA34 13(2) 19Sch 2, 4 13/01/06 10/03/06 Downing View Version 5.1 Page 25 Care Home Regulations is available for inspection at all times (for all staff working in the home). *Please note that from 26/7/04 Schedule 2 has been updated within the amended Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004.. [Previous timescale of 31/3/05 not met.] Also, from November 2005, new CSCI guidance is in place regarding the storage and retention of staff vetting records. Arrangements should now be made in line with this guidance. 18(1)(c)(i) Ensure that staff induction 30/11/05 training is LDAF [learning disability award framework] accredited to provide underpinning knowledge for progress towards achieving national vocational qualifications [NVQs]. [Previous timescale of 31/3/05 not met.] 18(1)(c)(i) Ensure that all members of staff 30/11/05 have an up to date training and development plan. This must include details of NVQ training so as to ensure that the home meets the target of 50 of staff with NVQs by the end of 2005. [Previous timescales of 31/8/04 and 31/3/05 not met.] 26 The Responsible Individual must 30/11/05 carry out monthly unannounced visits to the home and prepare a report of findings. Copies of the report must be sent to the CSCI and kept in the home. DS0000033029.V274923.R01.S.doc Version 5.1 Page 26 6 YA35 7 YA35 8 YA39 Downing View 9 YA40 17 [Previous timescale of 31/3/05 not met.] Ensure that the homes written policies and procedures are cover all the topics set out in appendix 2 of the national minimum standards for younger adults. Policies must include those relating to death of a service user, smoking and alcohol, sexuality and relationships and individual planning and review. [Previous timescales of 31/8/04 and 31/3/05.] 30/11/05 10 YA35 11 YA39 Not assessed on this occasion. 18(1)(c)(i) Ensure that all members of staff have an up to date training and development plan, which includes specialist training, aimed at meeting service users’ individual and collective needs. 24 Ensure that the results of the quality assurance questionnaires are made available to staff, service users and their representatives; including information on any proposed actions to address the suggested improvements. 28/02/06 10/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Downing View DS0000033029.V274923.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Downing View DS0000033029.V274923.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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