Inspection on 12/04/06 for Fairhaven [Gloucester]

This inspection was carried out on 12th April 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fairhaven [Gloucester] 25/09/07

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 Fairhaven Wolesley Road Elmbridge Gloucester Glos GL2 0PJ Lead Inspector Mr Richard Leech Unannounced Inspection 12th April 2006 09:30 Fairhaven DS0000066990.V290752.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 Fairhaven DS0000066990.V290752.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. Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Fairhaven Address Wolesley Road Elmbridge Gloucester Glos GL2 0PJ 01452 530112 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) The Brandon Trust Miss Abigail Clare Rees Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (3), Physical disability (2) of places Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 05/01/06 Brief Description of the Service: Fairhaven provides care for five adults with learning and physical disabilities. There are two bedrooms on the ground floor and three on the first floor. A stair lift is provided to make the upstairs more accessible. There is a lounge, kitchen and dining area as well as enclosed garden with a patio. The home is close to a range of facilities and is near to the city centre. There is a minibus suitable for transporting people in wheelchairs and a people-carrier for one of the service users. The home is run by the Brandon Trust, who took over as service provider in April 2006. Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Wednesday, lasting from mid morning to late afternoon. All of the service users were met, along with several members of the staff team and a visiting health professional. A brief visit was made on the following Tuesday to meet with the manager and to complete the inspection. During the inspection there was discussion with staff and service users, as well as general observation of life in the home. Various records were checked including samples of care plans, risk assessments, healthcare notes and medication records. Recommendations from the last report were not systematically checked, but should be given consideration if still applicable. What the service does well: What has improved since the last inspection? Progress has been made with reviewing and updating care plans, including retyping some in order to make them clearer. Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 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. Fairhaven DS0000066990.V290752.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 Fairhaven DS0000066990.V290752.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good policy and procedure framework helps to reduce the probability of inappropriate admissions being made, benefiting current and prospective service users. EVIDENCE: The Brandon Trust’s admissions policy and procedure (dated November 2000) was viewed. This appeared to comply with the National Minimum Standards and included points such as the need for a community care assessment (checked against the vacancy profile), a single point of referral and visits by the service user to the home. The Statement of Purpose gives information about the range of the needs the home aims to meet. There have been no new admissions since the last inspection. This standard is assessed as met on the basis of a good framework for admissions being in place. The manager said that she had not overseen an admission but would follow the Trust’s policy and seek support from senior managers and colleagues. Client contracts as well as the Statement of Purpose and Service Users Guide will require review and update given that the service provider has changed. Given that this had just happened, a requirement is not made but it is expected that all necessary reviews and updates will be achieved with in a reasonable time period. Fairhaven DS0000066990.V290752.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 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care planning systems in the home are good, helping to promote the consistency and quality of care. Service users are offered meaningful choices. Where limitations on freedom are in place these are appropriately documented, promoting people’s safety with the minimum of restriction. The home has appropriate systems for assessing and managing risk, promoting people’s independence whilst identifying any necessary support or intervention. EVIDENCE: The Brandon Trust has a policy on person centred planning. Essential lifestyle plans (a form of person centred planning) are written in the home and were seen to be regularly reviewed and updated. These operate in parallel with a more traditional form of care planning providing guidance for staff in areas such as personal care, communication, eating & drinking and activities. These plans were very comprehensive and covered appropriate areas. Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 10 There was evidence on file of regular review and update of care plans. Whilst many had been retyped (as recommended in the last report), there remained somewhere handwritten additions were beginning to compromise legibility or where important new information was not fully incorporated into the plan. Examples included one person’s care plans on foot care, weight control and pressure care. However, it is recognised that this is an ongoing process. Care plans included an emphasis on communication and on establishing and responding to people’s preferences and choices. Staff spoken with gave examples of how this operated on a day-to-day basis. Certain restrictions operating in the home, such as the use of a stairgate in one doorway at night, were appropriately documented. Although the kitchen is locked (and the reasons documented) service users were observed being given access to the kitchen throughout the day. Some people took part in cooking and others make themselves a drink with support. The Trust also has a policy about risk taking for residents. This refers to the need to involve the person and to assess the risk and whether it is worth taking (considering the benefits of a proposed course of action/activity). Risk assessments provided evidence of the appropriate consideration and management of risk issues. For some assessments it was not clear when reviews had last taken place. In certain cases the month but not the year of the review was recorded. The review date should be fully clear. The Trust has a missing person’s policy and procedure. Fairhaven DS0000066990.V290752.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): 12, 13, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Appropriate support is provided for service users to take part in activities in the home and community, which meet their individual needs and interests, thereby promoting their quality of life. Relationships with family, friends and others are strongly supported, helping service users to maintain contact with important people in their lives. Service users benefit from flexible routines and an approach, which respects their rights and individuality. A balanced diet is provided reflecting service users’ needs and choices, respecting their rights and promoting their health and wellbeing. EVIDENCE: Activity plans, daily records and handover sheets provided evidence of varied, individual programmes for each person. Some people had fewer activities in the community, but staff were able to explain this in terms of factors such as the person’s age and the choices and preferences that they communicated to Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 12 the team. Activities included accessing facilities in the community such as day centres, hydrotherapy and shops. Holidays were planned for some service users in the near future. Evidence that the team supported service users to maintain contact with family came from discussion with staff, daily records, the communication book and care planning. This included evidence of appropriate people being invited to care planning review meetings, and of service users being supported to pay their respects to deceased family members. Staff spoken with described service users having flexible routines based around their needs and choices. This was observed during the inspection, for example with people getting up and having breakfast at different times and with each person’s routines and activities during the day being very different. Discussion with staff and general observation also provided evidence of people’s rights being respected, for example in terms of where they chose to spend time and having requests responded to. Four-weekly menus were seen. These appeared to offer a varied and balanced diet. Staff described providing alternatives if requested/required. Service users’ care plans referred to issues around eating and drinking where relevant. There is also additional guidance available for staff, such as around low fat diets. A mealtime was observed. There was a relaxed atmosphere with people eating at their own pace and receiving appropriate support. Service users were also seen having breakfast at different times and in the room they chose. Fairhaven DS0000066990.V290752.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, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate support is provided with personal and healthcare needs, promoting service users’ dignity and wellbeing. There is scope to improve systems for handling medication in the home in order to minimise the risk of errors and further promote service users’ safety. EVIDENCE: Care plans for personal care provided clear guidance for staff and placed a strong emphasis on respecting people’s choice, privacy and dignity and on promoting independence. Staff spoken with described how this worked in practice, and demonstrated a commitment to upholding these values. The home’s diary and communication book provided evidence of regular contact with a variety of healthcare professionals. Service users’ individual healthcare files provided further evidence that service users are supported to access the services that they need to stay as well as possible. Weight charts are completed, as well as other forms of monitoring where necessary. Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 14 Service users’ care plans refer to individual health needs as identified. Health Action Planning has begun in the home but further work is needed to develop this. A visiting healthcare professional provided feedback, saying that the team had a good knowledge of people’s needs and were very skilled. They indicated that staff worked well with external professionals, was very client centred, and advocated very well for service users. Some medication administration records for a four-week period in 2006 were checked. The following issues were noted: • • • No entry was made in the allergies box. This should be completed, even if to write ‘none known’. A handwritten entry had not been signed. This should be done, and ideally should be double signed by a second designated person who checks the entry for accuracy. There were several gaps in the record, such as for one person on 01/04/06 and 28/03/06 and for another service user on 23/03/06. Service users have individual medication care plans. There was evidence that these were regularly reviewed. Appropriate specialist care plans and protocols were seen to be in place. The manager and staff reported that medication training consists of an in-house package combined with a college course about the safe handling of medication and, as far as possible, training about the system in use in the home from the supplying pharmacy. The manager said that following a medication error in November 2005 all staff were undertaking competency reassessments. During the inspection external and internal medications were separated as per guidance from the Primary Care Trust. The Brandon Trust’s medications policy was viewed. Fairhaven DS0000066990.V290752.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to support service users to express concerns and complaints, helping them to feel listened to. There are appropriate arrangements in the home and Trust to help protect service users from the risk of harm and abuse. EVIDENCE: Guidance was on display in the office about communication and listening. The Brandon Trust’s complaints policy, dated June 2003, was available in the home. This described dealing with the issue informally as far as possible, and then described the system for handling formal complaints. The policy described the need to create an environment where people feel able to raise issues. Staff spoken with described how people expressed that they were unhappy and the ways that they responded, giving examples. The Brandon Trust’s policy on whistle blowing was viewed. This provided clear, appropriate guidance for staff. The policy on safeguarding adults (dated December 2005) was also seen and appeared to be thorough. Staff spoken with described the systems in place to help protect service users from harm and abuse, and discussed how they would act if they had any concerns. They described a culture where people felt able to sensitively challenge and question practice, encouraging openness, reflection and discussion. New care plans which describe red, amber and green behaviours have been written, following advice from the Trust’s PRT coordinator. Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 16 Most staff had received input about abuse and adult protection, either through a stand-alone course or as part of NVQ or LDAF work. A letter from the Employee Development Coordinator for the Brandon Trust provided evidence of a training strategy which, amongst other things, included a commitment to staff having training in the protection of vulnerable adults. Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comfortable, homely and clean environment is provided, enhancing service users’ quality of life and wellbeing. EVIDENCE: Communal areas were pleasantly decorated and reasonably spacious. Bedrooms were seen to be personalised and service users spoken with indicated that they liked them. Service users are supported to lock their doors if they express a wish to. There is a bathroom with an adapted bath on the ground floor and a shower room upstairs. Staff reported that these facilities meet service users’ needs. A stairlift is used to support some service users up and down the stairs. Total communication symbols and other forms of communication are used throughout the home. It was agreed with the manager that the dining room should be redecorated as the décor is beginning to look tired and the wallpaper borders are starting to peel away. This should be done in consultation with service users as far as Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 18 possible. A wall by the entrance to the ground floor bathroom and the dining room should also be redecorated since the paintwork (and possibly some plaster) is cracked and worn. The home was clean throughout and measures were in place to promote hygiene, such as provision of liquid soap and paper towels. Some staff attended a course on infection control in November 2005. A cleaning schedule was viewed. Some recorded fridge temperatures were noted as being on the high side (89°C). This should be checked and adjustments made if necessary to ensure that food is stored within an appropriate temperature range. A visiting professional felt that the home was always clean and welcoming. Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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 & 35 Quality in this outcome area was adequate. This judgement is made using available evidence including a visit to this service. Staff are skilled, competent and appropriately trained, promoting the quality and consistency of care. Additional training is required in one area in order to equip staff with necessary knowledge and skills for their roles. Recruitment procedures are generally satisfactory, although one aspect needs attention to ensure that risks of employing unsuitable staff are minimised. EVIDENCE: Documents in the office described people’s delegated roles and responsibilities (such as for health & safety and total communication). There was also a description of the role of team leader and of keyworker. A mission statement was on display as well as communication guidelines and philosophies. Staff spoken with expressed a clear commitment to values and principles, such as total communication and respecting people’s rights. A night shift file was in the office. Some of this needed updating, such as on call procedures which related to the Mayfield Trust. Clearly there will be much documentation that requires similar review and update. As stated, these will not appear as requirements and recommendations at this stage in view of how Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 20 recent the transfer has been, but may once a reasonable period has elapsed and key documentation could be expected to have been reviewed and updated. The communication book provided evidence of good communication within the home. The manager and all staff spoken with indicated that the team was very cohesive and worked well together. An agenda for a forthcoming staff meeting was in the office. Some updates about issues such as new food safety laws were highlighted in the office for staff to read. Staff spoken with were familiar with care plans and were able to consistently describe issues and responses relating to people’s needs, communication, conditions and behaviours. A newsletter as well as letter from the Brandon Trust’s employee development coordinator provided evidence of the new service provider’s commitment to supporting staff through NVQs and LDAF training. Discussion with the manager and staff provided evidence that the majority of staff have completed NVQ level 2 in health and social care, or will shortly be undertaking the course. Two staffing records were checked. These contained information as required under the Care Homes Regulations 2001. One application form had gap in the employment history from December 1999 to May 2001. The manager said that this had been explored during the interview. However, written explanation of this gap must be available on file. As noted, a letter from the Brandon Trust’s Employee Development Coordinator provided evidence of clear training strategy. The extent to which this is achieved will be considered in future inspections. Training records for two staff provided evidence of mandatory training being up to date and of a range of additional training opportunities being available for staff. These included working with older people with mental health difficulties, infection control, risk assessment, vehicle safety training and working with older people with a learning disability. One service user has recently been diagnosed with a particular condition. The manager and staff reported that a consultant was coming to the home to give some input around this and what could be expected, though this was being regarded just as an introduction to the issue. A requirement is therefore made about all staff receiving appropriate training on this issue. The manager said that the Brandon Trust had already been approached about this. This is evidence of a proactive response, given that the diagnosis was very recent. Organisations such as BILD may also be able to provide relevant literature about learning disability and dementia. Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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 Quality in this outcome area was good. This judgement is made using available evidence including a visit to this service. The home is well run, promoting positive outcomes for service users. Health and safety is managed effectively, making the home a safe place to live and work. A quality assurance system needs to be established, so that people living in the home and others involved in their care can give feedback about the service and how it should develop. EVIDENCE: The manager had completed the Registered Manager’s Award and was taking NVQ level 4 in health and social care, having achieved levels 2 and 3. Staff spoken with felt that the home was well managed. Further evidence of this came throughout the inspection, as described in previous sections of the report. Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 22 In the last report a requirement was made about establishing a quality assurance system. The timescale (30/04/06) had not yet expired. However, the manager said that she had been researching approaches and was formulating a system based on obtaining feedback from service users, staff and others involved with the home. The manager has also approached Brandon Trust for information about their systems. The timescale is extended, in acknowledgement of progress being made but a system not yet being in place. The Brandon Trust’s health and safety policy was seen, along with an accompanying manual setting out policies and procedures in different areas such as moving & handling, accidents, Coshh and food safety. As noted, staff have delegated responsibilities, some relating to different aspects of health and safety. Portable appliances had been tested in June 2005. Documentary evidence of equipment being serviced at appropriate intervals was also seen. The fire log provided evidence of testing of alarms and emergency lighting at suitable intervals. Records were seen of a weekly vehicle safety check. A new Brandon Trust template for a fire risk assessment had been received in the home and was awaiting completion. The manager said that this would be done very soon and would replace one in an older format. Staff spoken with felt that the home was a safe place to live and work. Fairhaven DS0000066990.V290752.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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 4 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 4 x 2 x x 3 x Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? NO 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 YA20 Regulation 13 (2) Timescale for action Ensure as far as possible that the 05/05/06 medication administration record provides a complete record of the administration of all medications. Ensure that satisfactory written 30/05/06 explanation of any gaps in employment is available for all staff. All staff must receive appropriate 31/08/06 training about the condition that one person has been diagnosed with, as described in the text. Establish and maintain a system 30/06/06 for reviewing and improving the quality of care provided. Make provision for consultation with service users and their representatives as part of this. Timescale of 30/04/06 had not yet expired, but extension agreed. Requirement 2 YA34 Sch.2 (7) 3 YA35 12(1) 18(1)c(i) 24 4 YA39 Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 25 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 YA6 YA9 YA19 YA20 Good Practice Recommendations Continue work on retyping care plans when handwritten additions begin to compromise their legibility. Ensure that the review dates of risk assessments are clear. Continue developing individual health action plans. • The allergies section on MAR charts should be completed, even if to write ‘none known’. • Handwritten entries on MAR charts should be signed by the author, and ideally should be double signed by a second designated person who checks the entry for accuracy. • Redecorate the dining room. • Attend to the wall by the entrance to the ground floor bathroom/dining room which has worn and cracked paintwork. Check fridge temperatures and ensure that food is being stored within an appropriate temperature range. 5 YA24 6 YA30 Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Fairhaven DS0000066990.V290752.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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