Inspection on 17/08/06 for Fen House

This inspection was carried out on 17th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fen House 30/08/07

Fen House 18/10/05

Similar services:

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Dolphin Court

Fen Road

Wakes Hall

165 Putnoe Lane

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

CARE HOME ADULTS 18-65 Fen House 143 Lynn Road Ely Cambridgeshire CB6 1DG Lead Inspector Nicky Hone Key Unannounced Inspection 17th August 2006 11:45 Fen House DS0000061337.V293050.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 Fen House DS0000061337.V293050.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. Fen House DS0000061337.V293050.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Fen House Address 143 Lynn Road Ely Cambridgeshire CB6 1DG 01353 667340 01353 653155 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 Disabilities Trust Care Home 25 Category(ies) of Physical disability (25) registration, with number of places Fen House DS0000061337.V293050.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2005 Brief Description of the Service: Fen House is a purpose built home which opened in February 2005 in a residential area on the outskirts of Ely. The home is owned and managed by the Brain Injury Rehabilitation Trust and is for people who have suffered a brain injury. All the service users who live at Fen House are funded by their local authority, or by a solicitor in medicolegal cases. The building is divided into two units. Each unit has its own front entrance from the car park at the front of the building, and the units are divided at the rear of the building by double doors across a corridor. One unit has 10 places and is for short-term rehabilitation. The other unit has 15 places for people who need a longer period of rehabilitation. All service users bedrooms and living accommodation are on the ground floor. All bedrooms are single and have an ensuite toilet, washbasin and shower. There are three dining rooms, three lounges, a games room and a smoking room as well as a main kitchen and laundry. Two of the lounges and the smoking room open onto a large enclosed central courtyard which has been attractively landscaped in a modern style. There is a domestic-style kitchen and laundry in each unit. These are used as part of service users’ rehabilitation programmes. One of the therapy rooms contains physiotherapy equipment. The first floor of the home has offices, meeting rooms, therapy rooms and staff facilities. The staff team consists of the manager, two assistant managers, senior tam leaders, rehabilitation support workers, cooks and domestic staff, as well as a team of qualified therapists, including physiotherapists who are linked to the Princess of Wales hospital which is over the road. Fen House DS0000061337.V293050.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection started with a visit to the home on 17/08/06. The inspector spent time talking with service users, staff, assistant managers and the acting manager, as well as walking round the building and inspecting records. After the inspection the Commission for Social Care Inspection (CSCI) sent a “Have your say about….” survey form to each service user. Seventeen forms were returned to the CSCI and some of the responses, including some direct comments, have been included in the report. At the time of the inspection the acting manager, who started working at Fen House in March 2006, had not applied to the CSCI for registration. She was hoping to do so before going on maternity leave at the beginning of October 2006. Arrangements had been made for one of the assistant managers to manage the home in her absence. At the time of the inspection the home was fully occupied, with twenty-five service users living there. What the service does well: Of the seventeen people who responded to the CSCI survey, about half ticked all the ‘yes’ boxes to indicate they are satisfied with the service they get. One person wrote “I am glad I am a client at Fen House. If I had not come here any rehabilitation I may have received in the community would’ve been hit and miss at best, and any progress would’ve taken years”. Another person wrote “Fen House is very good”. Detailed assessments of each service user’s needs are carried out before the person is offered a place at the home, and risk assessments are completed to ensure the person’s safety. The staff respect service users’ confidentiality and support people to maintain and develop relationships. The home has a good complaints procedure and the majority of the service users who responded to the service indicated that they know who to talk to if anything is wrong. Generally the standard of decoration, furnishing and maintenance of the home is good and it is kept clean and fresh. Staff files seen contained all the information needed before a new staff member can start work, and staff receive regular supervision to make sure they are doing their jobs well. Fen House DS0000061337.V293050.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Fen House DS0000061337.V293050.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 Fen House DS0000061337.V293050.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, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know that an assessment will be carried out to make sure the home can meet their needs. EVIDENCE: The home has a statement of purpose and service user guide which will be updated when a new registered manager is in post. Seven service users who responded to the CSCI survey felt they had received enough information about the home before they moved in, and seven said they had not. Thorough, detailed assessments are carried out for each service user before the home agrees that they will be able to meet that person’s needs. Fen House DS0000061337.V293050.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, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user plans need more detail to adequately provide staff with the information they need to satisfactorily meet service users’ needs. EVIDENCE: We looked at the files of three service users. The organisation of the files has improved and generally the information on the files was satisfactory, although the ‘client summary’ could be in more detail. There was good, detailed information on one person’s file, but it was not signed or dated. Each file contained some guidelines relevant to that person, for example, for one person there were guidelines about swimming and communication. There was also a detailed exercise programme on the file. However, there were no details on the file relating to all aspects of care so that staff could provide consistent care. Fen House DS0000061337.V293050.R01.S.doc Version 5.1 Page 10 The acting manager explained that each person has regular reviews. A review is held after ten weeks for people admitted for the shorter term (12-week) rehabilitation. If the person is not ready to leave, their stay can be extended. We saw risk assessments on the three service users’ files we looked at. It was good to see these were signed by the service users but they should also be signed by the assessor. There was evidence that the risk assessments are regularly reviewed. The acting manager told us that any restrictions on service users are agreed with that person and written up as part of their contract. Two service users that we spoke to were not happy. They both felt that the home treats all the service users the same. One person felt the home starts with the assumption that service users are not able to do anything, and are a risk to themselves and other people. This person said they have been “unbelievably restricted”. Service user files are kept in the duty office which is always locked so that service users know their confidentiality is respected. One service user commented “staff never talk to me about other service users”. Fen House DS0000061337.V293050.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): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Opportunities for service users to engage in appropriate activities to increase their personal and social development need to continue to improve so that all the service users are satisfied with the care they receive. EVIDENCE: Service users come to Fen House with a view to moving on to more independent living, therefore the aim of the home is that everything that takes place is to promote service users’ personal development. One service user said there had been a slow start, but the staff “are trying to assess what I need” and are making a lot of effort to “personalise my programme”. Another service user said “it needs more individualised assessment and more personalised treatment for rehabilitation back into modern life”. The acting manager said the home has realised that, for more able service users, the Fen House DS0000061337.V293050.R01.S.doc Version 5.1 Page 12 assessment processes and procedures followed by the therapists are too slow. She said this was being changed. Each service user has their own weekly programme of day-time activities. The activity programmes that we saw looked quite full, although one person commented that the therapists frequently arrive late for, or cancel, appointments. There were a lot of evening activities listed on the board in the duty office. Staff said that sometimes these do not take place, either because the service users change their minds and decide not to take part in the activity, or there are not enough staff to take people out. One service user said that sometimes he asks to go out but is told there are not enough staff. The home employs an activities coordinator who completes a ‘leisure interests’ check list with each service user. Several groups are now up and running, such as a gardening group and a topical issues discussion group. Of the seventeen people who responded to the CSCI survey, about half wrote that they are able to make decisions about what they do each day, and that they can do what they want to do during the day, in the evenings, and at weekends. Three people indicated they are not able to make any decisions about what they do, and another two wrote they can only make decisions sometimes as the day-time programmes are arranged by the staff. Three service users commented on the lack of physical activity, all saying they had expected more. One person said they had been asking “for a very long time” to join a local gym as the equipment in the home was not adequate: the acting manager told us this had been arranged, although at the time of this inspection, the sessions had not started. One person wrote they need more outdoors activities, and another “I feel I do not get enough work and sessions at the gym or enough swimming, and I need more speech and language sessions”. We saw photographs on a board in the corridor of “The Great Escape”. This was a period of six weeks in the summer, for two sessions a week, when service users planned activities both at and away from Fen House. There were photographs of a Hawaiian Night that had been held at the home, when there was a barbeque and games. Service users who wanted to had made paper flower necklaces to wear. At the time of the inspection service users were planning a Halloween night. The home holds money for some of the service users and a ‘bank’ opens at set times twice a day in a room on the community integration unit. This encourages service users to learn to plan ahead. Service users are encouraged to eat their meals in one of the dining rooms. Lunch is a light meal, usually soup and sandwiches followed by yoghurt or fruit. A choice of main course is offered for the main meal of the day which is Fen House DS0000061337.V293050.R01.S.doc Version 5.1 Page 13 served in the evening. Two service users we spoke with told us that they choose each morning which of the two choices they would like for the evening meal and they said there is always enough food. One of the choices is usually a vegetarian option. We were told that service users who are able to can cook their own breakfast, otherwise people help themselves to cereals and toast. However, two service users spoken with said there is no cooked breakfast available. If they want toast and a hot drink they have to make them in the therapy kitchen after they have eaten their cereal in the dining room. Fen House DS0000061337.V293050.R01.S.doc Version 5.1 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 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 adequate. This judgement has been made using available evidence including a visit to this service. Documentation is not yet good enough to evidence that personal support and healthcare needs are met. EVIDENCE: There was little evidence on the files seen of the personal and healthcare needs of individual service users, and therefore it was difficult to judge whether or not these are met adequately. One of the senior staff has responsibility for ordering medication and ensuring medication issues are dealt with correctly. The drugs trolley is kept in a locked cupboard in a locked office and the team senior keeps the keys with them at all times, so medicines are kept very secure. Some Medication Administration Record (MAR) charts were seen and had been completed and signed correctly, except that the number of tablets received in blister packs is not recorded. The temperature of the medication storage room is recorded daily. Fen House DS0000061337.V293050.R01.S.doc Version 5.1 Page 15 One of the senior staff told us that at present no service users keep their own medication and take it themselves. One person we spoke with said they had been taking their own medicines before coming to Fen House and wanted to carry on doing so. The staff were assessing this person’s ability to carry out this task safely. Staff who administer medication have been trained by one of the assistant managers who received training in medication administration at her previous place of work. Staff shadow other members of staff and are then shadowed until they are assessed as competent by the assistant manager. We were told they have also had training from members of the East Cambs and Fenland Primary Care Trust, and do refresher training in-house every year. Fen House DS0000061337.V293050.R01.S.doc Version 5.1 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 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 adequate. This judgement has been made using available evidence including a visit to this service. Staff training is not adequate to ensure that all staff are fully aware of issues around abuse and protection so that service users are kept safe. EVIDENCE: We looked at the home’s complaints record. Each complaint is added to a list in date order and given a number. All the information relating to that complaint, such as letters written, statements taken and so on, is kept in a file. Training records showed that some of the newly appointed staff have not received training in the Protection of Vulnerable Adults. However, the acting manager said that POVA is covered within induction and in tutorials. Fen House DS0000061337.V293050.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, 25, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally the standard of the environment in this home is good, providing service users with a safe, clean and comfortable place to live. EVIDENCE: This home has only been open for eighteen months, so most of the building is still well decorated and most of the furniture looks new. The modern, minimalist style of decoration, and the design of the building with its wide corridors, gives a bright, airy and clean feel. Some attempts have been made by the acting manager to introduce items such as additional pictures and plants to give a more homely atmosphere, but there are areas which still feel quite clinical. Bedrooms are all the same. Each has an ensuite toilet, washbasin and large walk-in shower. The rooms give each person a good deal of space and service users are encouraged to bring in the own belongings if they want to. Fen House DS0000061337.V293050.R01.S.doc Version 5.1 Page 18 Some issues on the ‘snagging’ list have not been made good by the builders, for example a large area of plaster has come off the wall by the therapy gym. A lot of paintwork on walls, doors and woodwork has been damaged, mainly because the decoration is not robust enough for the number of wheelchairs that are in use in the building. The acting manager said the maintenance would improve once the newly appointed maintenance man is in post. The home is kept very clean and smelt fresh throughout. Fen House DS0000061337.V293050.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, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff training records indicate that staff have not received adequate training for them to be able to do their job well. EVIDENCE: One service user we spoke to said “the staff are very helpful, very cheerful, very good”. An assistant manager and three team seniors lead the staff teams in each unit. These teams work the majority of their shifts in that unit. There is a team senior on duty on every shift who is responsible for running the shift. As with most new services, Fen House has seen quite a number of staff start work and leave. However, the acting manager said the teams are now settling down and staff are working better together. At the time of this inspection there were seven staff vacancies, but we were told that recruitment had been good recently and five new staff were waiting to start work once all the required references had been received. All the therapist posts had been filled, including appointing a consultant psychologist, so the acting manager felt the therapy side of the service could now develop. Fen House DS0000061337.V293050.R01.S.doc Version 5.1 Page 20 One of the service users we spoke with said the home does not employ enough staff, and another that “generally the staff are very good but they’re always saying they are understaffed”. One of the people who wrote to us said “quite often there are hardly any staff and I have to wait for help”. Another service user commented that there is “too much money spent on agency staff which means the full time staff are not paid enough”. One of the assistant managers now has responsibility for organising staff training and ensuring all staff keep their training up to date. At the time of the inspection she was trying to find evidence of the training undertaken by staff, and was bringing the records up to date. Records seen showed that the majority of staff have done moving and handling training. Some staff have done first aid, and some did fire training in October 2005. No staff have done infection control or food hygiene training. All staff must receive training in these five mandatory topics, and all staff should have at least five days of training each year. Some staff have also undertaken other training such as non-violent crisis intervention, basic brain injury and disability awareness training. Three staff are currently working towards a National Vocational Qualification (NVQ) in care level 2, and three are working towards level 3. It is planned that one of the assistant managers, and one team leader will start training to be NVQ Assessors in September. New staff are given an induction pack which they discuss in supervision. The home’s policy is that they shadow an experienced member of staff for two weeks, and undertake all mandatory training within the first two months. The assistant manager said she has purchased the Skills for Care Induction booklet which will be used for all new staff, and might be used in retrospect for all staff. She was working on a training programme to ensure all staff’s training meets the requirements. We looked at the personnel files of three staff members. All the information required by the legislation was on the files, including a completed application form, a health declaration, two satisfactory references, a Criminal Records Bureau check, evidence of identification and a photograph. Gaps in employment are explored at interview. The acting manager said that all staff had received supervision. Supervision records were in place on the files we looked at and showed that staff had had supervision sessions recently. Fen House DS0000061337.V293050.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, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has a good understanding of the areas in which this home needs to improve so that the best possible standard of support and development is offered to the service users. EVIDENCE: The acting manager at the time of this inspection, Denise O’Brien, started work at Fen House in March 2006. She said she hoped to apply for registration as the manager before going on maternity leave in October 2006. One of the assistant managers had been identified as being able to manage the home during Mrs O’Brien’s maternity leave. The home has started a system for getting views on whether is offering a quality service. Service users complete a customer satisfaction survey before Fen House DS0000061337.V293050.R01.S.doc Version 5.1 Page 22 each review. A questionnaire is sent to commissioners and relatives after the review: the acting manager said no replies had been received so far. The organisation requires the person managing the home to complete audits of various aspects of the service. Client meetings are held, as well as the daily orientation meetings, where service users are encouraged to make their views known. Visits by a representative of the registered provider are carried out monthly and a report written as required by the regulations. Training records showed that some staff had fire safety awareness training in October 2005. Staff should do refresher training in fire safety awareness at least twice a year, which could include a fire drill that all staff must do at least once a year. Staff training records showed that not all staff have had training in health and safety related topics (see Staffing section of this report). Records of tests of the fire alarm system showed that tests had been done weekly as required except for a period in June/July 2006 when some tests had been missed. The home must make sure that the fire alarms are tested every week. Records of tests of the emergency lighting system could not be found: evidence must be available for inspection to show that the lights are tested at least monthly. We were pleased to see that the chair in front of the lift seen at the previous inspection has been removed. It has been replaced with a lock on the lift to stop service users in wheelchairs using the lift alone and possibly putting themselves at risk. Fen House DS0000061337.V293050.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 3 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 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 3 3 LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X 2 2 X Fen House DS0000061337.V293050.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 YA12 Regulation 16(2)(m) & (n) Requirement Service users must be offered a full range of meaningful activities and leisure pursuits. This was partly met: a revised timescale has been given. Service user plans must include details of personal support and healthcare needs. Timescale for action 31/12/06 2 YA18 15 31/12/06 3 YA20 18(1)(c)(i) The registered person must ensure, and provide evidence, that staff who administer medication are appropriately trained. 18(1)(c)(i) All staff must receive training in the Protection of Vulnerable Adults. 23(2)(d) All parts of the home must be kept reasonably decorated. The registered person must ensure that adequate numbers of staff are employed to meet the needs of the service users. 31/12/06 4 YA23 31/12/06 5 YA24 31/12/06 6 YA33 18(1)(a) 17/08/06 Fen House DS0000061337.V293050.R01.S.doc Version 5.1 Page 25 7 8 YA41 YA42 17(2) and sch 4(14) Records of tests of fire equipment must be maintained. 17/08/06 18(1)(c)(i) All staff must receive training in 31/12/06 health and safety related topics such as fire safety, food hygiene, first aid, manual handling and infection control. 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 Refer to Standard YA17 Good Practice Recommendations The home should consider a way of providing breakfast that meets service users’ needs in a more homely way. 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