Inspection on 23/10/06 for Ferrers Drive (3)

This inspection was carried out on 23rd October 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 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ferrers Drive (3) 19/12/07

Ferrers Drive (3) 18/01/06

Ferrers Drive (3) 21/09/05

Ferrers Drive (3) 28/02/05

Ferrers Drive (3) 21/09/04

Ferrers Drive (3) 11/02/04

Ferrers Drive (3) 17/11/03

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 Ferrers Drive (3) 3 Ferrers Drive Grange Park Swindon Wiltshire SN5 6HJ Lead Inspector Bernard McDonald Key Unannounced Inspection 23rd October 2006 10:00 Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ferrers Drive (3) Address 3 Ferrers Drive Grange Park Swindon Wiltshire SN5 6HJ 01793 875898 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) Ian Charles Miss Michelle Stephen Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2006 Brief Description of the Service: 3 Ferrers Drive is a modern two-storey house with a large garden. The homes philosophy states that the aim is to …provide a warm homely atmosphere which is beneficial to our residents. Independence, freedom of choice will be encouraged while offering support without intrusion. We are committed to encouraging service users to reach their full potential wishes and dreams and to strive for as much independence as possible. This service offers care and accommodation to both men and women who have a learning disability. The service replicates principles of ordinary living and strives to provide services that take account of social role valorisation principles. Each service user has their own bedroom and share communal areas. The service is designed for people that can manage stairs and want to live with others. Any behaviours must be manageable within a small domestic environment. The home, which is located in the Grange Park area of Swindon, is owned by a partnership that trades as Ian Charles. They have one other similar care home nearby. The home has a fulltime manager and a small staff team. Typically there are two members of staff on duty throughout the day. At night time the staff take it in turns to sleep at the home and to be available to assist with any night time needs or emergencies as they arise. Service users are expected to engage in day activities during the week. Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed over six and three quarter hours. There was opportunity to meet with all service users living in the home to obtain their views on the care they receive. In addition one member of staff was interviewed in private. The registered manager was available to assist with the site visit. As part of our pre inspection methodology the views of service users, their relatives and relevant stakeholders were obtained. The views of the relative of one service user who was visiting the home at the time of the site visit were also obtained. The overall comments received were of general satisfaction with the service provided at the home. The Range of fees were not made available at this inspection The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? The home has taken steps to improve the way it recruits new staff. The sample of recruitment records examined showed that all staff now receive a satisfactory Criminal Records Bureau check at enhanced level before commencing work at the home. More variety has been included in the menu resulting in healthier eating options being provided for service users. The majority of service users bedrooms have been decorated to give service users a much needed higher standard of décor in their rooms. Service users were very positive about the new décor in their room. One service user commented they were involved in choosing the colour. All but one staff member has now completed training in the safe administration of medication. Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5. The home is ensuring service users needs are assessed prior to moving to the home but they are failing to ensure the interim care plan provides sufficient information on how their needs should be met. Documentation needs to be updated to ensure service users have accurate information to inform them about the service provided and associated costs in order to be able to make an informed choice about their move. The Quality rating in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Since the last inspection one service user has been admitted to the home. Discussion with the manager and the member of staff on duty indicated the service user was receiving short-term care due to having to move from their previous placement. The long-term plan is for the service user to be accommodated at another home managed and operated by Ian Charles. Due to the need to move from their previous accommodation the move to the home was made as an emergency although a comprehensive assessment of the needs of the service user had been received at the home prior to the move taking place. The service user has yet to be made aware of the terms and condition of their stay. We were unable to establish the views of the service user in relation to their move but when asked the service user signed to say they were happy. Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 9 Following the site visit we were provided with a copy of the homes updated statement of purpose. The document states the home does accept emergency admissions and that within 24 hours an initial care plan will be developed and then finalised after 7 days. Examination of the service users care plan showed that an interim care plan had been developed but it was limited in content and covered only one page There were no details on how the needs of the service user should be met at the home or any direction for staff on the how the care should be provided. Discussion with three service users indicated they had no objections to the service user living in their home. One service user commented that they liked X. All service users had a contract outlining the terms and conditions of their stay. However the contracts did not specify the actual cost of the placement. The service user guide also needs to be updated to reflect the total fee payable and the arrangements for paying the fee. Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Information held in service users care plans is confusing and needs to be collated into one working document. Individual risk assessments are in place and every effort is being made to ensure service users are able to make decisions about their life. The Quality rating in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Examination of records showed all service users had a plan of care. All care plans were examined and three care files were examined in more detail. Information on how service users needs are to be met in the home was difficult to extract. Four service users each had a large lever arch file and smaller folder, which constituted the care plan. Discussion with the member of staff on duty indicated that the smaller of the two files is considered to be the care plan that staff work with. Information contained in the two files would constitute a reasonable care plan as combined, it covered personal care, health needs and risk. However as a stand-alone document care plans were confusing and repeated information, which was not always recorded the same. For example activities / daily activities; one file contained detailed information on what activities the service user takes part in while in the second file the information Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 11 relating to activities was blank. A further example was one file showed care plans were being updated while the information relating to care reviews in the second file was blank. The relative of one service user confirmed they had recently attended a care plan review meeting. One service user confirmed they were aware of their care plan and had been to their meeting. Deficits found in the care plan of the service user recently admitted have been referred to earlier in this report. The tools are already in place for developing a comprehensive care plan but consideration needs to be given to collating and updating the information into one working file. This would ensure staff are working towards the same model of care and ensure service users needs are more effectively met. The care plan of one service user had been updated following an increase in the challenges they present. Risk assessments had also been amended to reflect the risks associated with their care. The home has yet to ensure staff are trained in managing difficult and challenging behaviour and the requirement made at the last inspection had not been met. The failure to ensure staff are trained in managing extreme behaviour puts the service user and staff at risk. Information on advocacy services is held at the home and one service user has made use of the service as part of their transition to the home. Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. The home is making every effort to ensure service users are involved in the local and wider community and are able to take part in appropriate leisure activities. Visitors are made to feel welcome and improvements have been made in providing a healthy diet. The Quality rating in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users are being supported to attend day services of their choice. Since the last inspection one service user is accessing a new day care service. The service users stated it was their choice to go and that they “really enjoy it”. There is evidence to show the home is making good use of local community resources such as swimming baths, local gym, walks in the park and trips out. Discussion with staff confirmed that they clearly see supporting service users in the community as part of their role. Each service user has a weekly activity planner and one service user commented they had recently started going to the gym. Unfortunately service users have not been away on holiday this year although the manager reported a short holiday is being planned for the latter part of the year. Discussion with service users and staff on duty confirmed Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 13 they had been away for day trips to Cardiff Bay, Barry Island and a trip to the Zoo. Service users daily records confirmed their participation and enjoyment of these activities. To encourage and promote service users independence each person has been able to obtain a bus pass. This pass enables service users to access not only the local transport routes but also wider areas around Wiltshire. One service user commented they use the pass to get into town on their own. There was opportunity to meet with the relative of one service user. They commented that they can visit at any time and are always made to feel welcome. As part of our inspection methodology comment cards were also sent to the relatives of service users. Feedback was generally positive. Discussion with one service user confirmed they had some responsibility for household tasks. One service user ‘laughed’ when asked if they enjoyed these tasks. Service users involvement in household tasks is documented in the care plans. One member of staff confirmed they provide support to assist service users with these tasks. A sample of weekly menus was examined. Some improvements have been made to the variety of meals being provided and more healthy eating options such as salad fresh vegetables and yoghurts are routinely included in the menu. Some meals are however repeated frequently eg. for Mondays out of six had a stir-fry for the evening meal and fish and chips were featured on Fridays. The menu is being developed in consultation with service users at their monthly meetings and one service user said the food was “good” while another commented it was “ok”. Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. The home is making every effort to ensure service users receive support in a way they prefer and their health care needs are being safely met. Medication is safely administered. The Quality rating in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The way service users wish to be supported in managing their personal care is reflected in their care plans. The recent appointment (subject to CRB) of a male support worker will give male service users a real choice on how and who they wish to support them with personal care. The home has an equal opportunities policy, though at the present time there are no staff employed from a minority community. One member of staff from the Afro Caribbean community has recently resigned. A sample of records examined show service users have been supported to develop a health action plan. In addition there is evidence to demonstrate service users specialist health care needs are quickly identified and responded to with appropriate referrals to health care professionals. Adaptations have been put in place to ensure the specialist needs of one service user are safely met. Service users with communication difficulties have been referred to speech and language therapists. Discussion with staff confirmed that if Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 15 required they would provide support to enable service users access their heath care appointments. This practice was observed on the site visit when the manager supported one service user to attend their Doctors appointment. Two comments cards were received from the service users doctors surgery. No adverse comments were made about service users health care at the home. Following a requirement made at the last inspection all but one member of staff has completed medication training. Certificates were not available in the home as the workbooks were with the assessor for verification. A sample of medication records was examined. Records showed medication was being accurately recorded. Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. The home is making every effort to ensure service users views are listened to and they are protected from abuse. The Quality rating in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Since the last inspection all staff have completed abuse awareness training. One member of staff confirmed they had received this training and stated they would have no hesitation in reporting any concerns affecting the welfare of service users. Certificates are available to demonstrate attendance at the training. The views off all service users were audited as part of our pre inspection information gathering. Discussion with service users confirmed they were happy living at the home. When asked whom they would speak to if they were unhappy one service user said “the manager”, while another said their relative. A copy of the complaints procedure is on display at the entrant to the home. No complaints had been received since the last inspection. The manager confirmed that she is not responsible for any service users benefits. However money was being held in the home on behalf of service users. A sample of the records and money were examined and demonstrated it was being accurately recorded and safely managed. Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 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, 26, 30 Improvements have been made to the overall décor of the building. The home was clean, tidy and maintained to a good standard. The Quality rating in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A tour of the building was made. All service users bedrooms have now been redecorated. One service user said they had helped choose the colour of their room. One service user commented they had everything they need in their room. The manager reported there are also plans to upgrade the bathrooms over the coming months. There is a large communal lounge and the overall standard of furniture and fittings is good. However the three-piece suite is beginning to show signs of wear and tear and consideration needs to be given to replacing it. Laundry facilities are sited in the dining area. Discussion with staff confirmed that on the rare occasions infected or soiled linen needs to be washed there is a further washing machine, which is well away from any food preparation areas. A copy of the Health Protection Agency infection control guidelines was available in the home but staff have yet to receive any infection control training. The manager stated that following the requirement made at the last inspection staff had been enrolled on infection control training but the course Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 18 had been cancelled. Records received following the site visit confirmed staff had been enrolled on this training and a new timescale will be made for compliance with this requirement. Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 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. Safe recruitment practices are being followed but more attention needs to be given to staff training to ensure they are competent and have the necessary skills for their position. The Quality rating in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Examination of the rota shows there are normally two members of staff on duty during the waking day. For staff recently appointed, the home has an induction booklet that meets “Skills for Care” induction standards. However examination of the booklets being used by two members of staff shows they had only partly filled it out and many of the pages were blank. There has been little progress made to the overall training completed by staff working at the home. No staff have commenced National Vocational Qualification (NVQ) training. The manager confirmed that four members of staff have been put forward for NVQ training and they are planning to start the award in November. No progress had been made in ensuring staff receive basic training in the principles of caring for adults with learning disabilities. Following the site visit a training record for each member of staff was sent to us. The records show that training is being planned for all staff in food hygiene, learning disability award framework, (LDAF) learning disability modules and infection control. In view of this progress the timescale for meeting the Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 20 requirements in the last inspection report will be extended. But compliance must now be achieved within the revised timescales. The recruitment records of two members of staff recently appointed to the home were examined in detail. Records showed there was an overall improvement in the recruitment practices at the home. Records examined contained a clear Criminal Records Bureau check (CRB) and Protection of Vulnerable Adults check (POVA). Two references had been received and confirmation of the identity of the staff members had been verified. More attention needs to be given to exploring gaps in prospective staffs employment history. Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 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. The manager needs to put into practice the training she has received to ensure service users benefit from a well run home. More attention needs to be given to improving quality assurance and ensure safe work practices are being followed. The Quality rating in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The manager has completed NVQ 4 in care and the registered managers award and has been the registered manager at the home for over ten years. However a number of requirements remain outstanding from the previous inspection report especially in relation to staff training. The manager needs to ensure these requirements are now met within the revised timescale to ensure the team she manages is trained for the work they perform. Since the last inspection quality assurance questionnaires have been sent to service users, their relatives and care managers. Comments received showed an overall satisfaction in the service provided at the home. The manager has Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 22 yet to provide a detailed report on the outcome of the questionnaires to the participants. In addition, the views of relevant stakeholders and staff working at the home must also be obtained and included in the quality audit. Examination of the fire safety procedures showed fire safety practices were being held at regular intervals. Discussion with one service user confirmed they were aware of what to do when the fire alarm goes off. Risk assessments have been completed on the absence of window restrictors and radiator covers as non are fitted at the home. Control of substances hazardous to health risk assessments had been completed for products held in the home. Gas safety checks had also been completed. Less evident were any records pertaining to staff training in safe working practices, in particular food hygiene, moving and handling and first aid, which must now be provided to all staff Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 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 2 3 X 4 X 5 2 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 2 25 3 26 3 27 X 28 X 29 X 30 2 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 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 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(1)(b) Requirement The registered person must ensure the service user guide and contract contains details of the total fee payable and the arrangements for paying the fee. The registered person must ensure that any service user who is admitted in an emergency has an interim care plan developed within 24 hours, which is then finalised within 7 days as stated in the homes statement of purpose. The registered person must ensure service users care plans fully reflect their needs and the support they require. The registered person must ensure staff receive training in managing difficult and challenging behaviour. This was a requirement at the last inspection. The timescale for compliance was 01/04/06 The registered person must ensure staff receives training in infection control. This was a requirement at the last DS0000003196.V304774.R02.S.doc Timescale for action 01/02/07 2. YA2 15(1) 01/11/06 3. YA2 15(1) 01/11/06 4. YA6 18(1)(c)(i)(ii) 01/04/07 5. YA30 18(1)(a)(c)(i) (ii) 01/04/07 Ferrers Drive (3) Version 5.2 Page 25 6. YA32 18(1)(a) 7. YA32 18(1)(a)(c) (i)(ii) 8. YA39 24(1) 9. YA42 18(1)(a)(c)(i) (ii) inspection. The timescale for compliance was 01/05/06 The registered person must ensure 50 of care staff have a minimum qualification at National Vocational Qualification level 2 in care. 50 of staff must be working towards the award by 01/01/07. This was a requirement at the last inspection. The timescale for compliance was 01/04/06 The registered person must ensure staff receive training in the principles of caring for adults with learning disabilities. This was a requirement at the last inspection. The timescale for compliance was 01/05/06 The registered person must ensure a detailed quality audit is completed based on seeking the views of service users their relatives, care managers and relevant stakeholders as to the way the home is meeting its main objectives. A copy of the completed report must then be sent to all participants of the audit. The registered person must ensure staff receive training in safe working practices including, food hygiene and moving and handling and first aid. 01/01/07 01/04/07 01/04/07 01/04/07 Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 26 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 Good Practice Recommendations The registered person should consider collating service users care individual care plans into one working document. The registered person should consider replacing the threepiece suite in the main lounge. The registered person should ensure that any gaps in a prospective member of staffs employment history is explored at interview and recorded. The registered person should ensure that staff who are completing their induction programme complete the workbook to demonstrate they have successfully competed their induction. YA24 YA34 YA35 Ferrers Drive (3) DS0000003196.V304774.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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. 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