Inspection on 09/06/06 for Firlawn

This inspection was carried out on 9th June 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Firlawn 04/11/08

Firlawn 07/11/07

Firlawn 07/11/06

Firlawn 09/12/05

Firlawn 03/05/05

Firlawn 11/11/04

Firlawn 28/04/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Firlawn Firlawn 402 Chessington Road West Ewell Surrey KT19 9EG Lead Inspector Helen Dickens Key Unannounced Inspection 9th June 2006 09:15 Firlawn DS0000013642.V299472.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 Firlawn DS0000013642.V299472.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. Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Firlawn Address Firlawn 402 Chessington Road West Ewell Surrey KT19 9EG 020 8786 0514 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) EMAS Limited Company Mrs Jess Puah Care Home 3 Category(ies) of Learning disability (2), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be 25 - 60 YEARS The admission of a service user in the category MD is for a named person only. 9th December 2005 Date of last inspection Brief Description of the Service: Firlawn provides services for up to three service users. The property is a bungalow, which comprises of a large lounge/dining room and small separate sitting area, single bedroom accommodation, kitchen, laundry and two bathrooms. There are no en-suite facilities however, the three bedrooms are sited near to the bathroom. An extra bedroom with en-suite facilities is nearing completion at the time of this report. The bungalow is located off a main road, with parking for 4 cars. There is a large garden to the rear of the property which is shared by the companys sister home Oaklawn next door. Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 8 hours and was the first key inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to March 2007. The inspection was carried out by Mrs. Helen Dickens, Lead Inspector for the service. Mrs. Jess Puah, the Registered Manager, and Mr. Charlie Puah, the Responsible Individual, represented the establishment. A tour of the premises took place and a number of files and documents, including residents care plans and staff recruitment files, were examined as part of the inspection process. Only two residents live at Firlawn at the moment and both were spoken to during the day. In addition one member of staff was also interviewed. The inspector would like to thank the residents, staff and Manager for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? All three Requirements made at the last inspection have been met. The new bedroom with en-suite facilities is almost complete with decorative work etc being completed to a high standard. The bedroom has been carpeted Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 6 and is now ready for the furniture to be put in. This room offers a lovely view of the garden and is near to the new ramp into the garden. A patio has been built and a ramp into the garden has been completed which means the garden has proper disabled access from the living room of Firlawn. 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. Firlawn DS0000013642.V299472.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 Firlawn DS0000013642.V299472.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): 2 Assessments for residents are good and therefore the needs and aspirations of residents are properly identified and are more likely to be met. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Original assessments on residents showed that there was a good overview of health and personal care needs, and health and social care professionals had been involved in various aspects of these assessments. Health needs had been particularly well noted and the resident’s care plans and risk assessments had been drawn up using these documents. There was evidence of social and religious needs being included, and resident’s families had had input into these assessments. The home’s policy on admission included pre-admission assessment activity with prospective residents, for example visits to the home and overnight stays, prior to admission. Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Care planning at this home is well done; residents have some input into decision making and are supported to take risks in their everyday lives. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans examined contained a good overview of resident’s needs and how these would be met. Specialist advice had been sought on relevant areas such as activities of daily living (from the occupational therapist) and eating (the speech therapist reported on the high risk of choking and how to avoid this risk). The weekly activities plan was on each resident’s file, together with instructions on how to minimise risk and manage certain behaviour patterns. Residents were assisted to make limited decisions and the manager said this was commensurate with their capabilities. For example their recent holiday had been chosen because residents like the seaside and they were shown some brochures to help them to choose. Another example given by the manager was that residents get up in their own time, and choose when they would like something to eat or drink. The home had contacted advocacy Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 10 services of behalf of residents and family members were involved with each resident. Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 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 and 17 Residents are assisted to take part in activities, and participate in the local community. Family relationships are encouraged and resident’s dietary needs well met. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident’s have a weekly plan of activities and this includes day care where there is a specific evaluation of goals to promote independence. Residents particularly enjoyed music therapy and aroma therapy, but other opportunities for eating out and to be sociable were also mentioned. One resident who does not like company is supported to take part in activities where they do not have to mix with others. Residents have access to local community facilities and like to eat out, go for picnics, and walk in the park. The residents do not use public transport as the home has its own vehicle. The manager said they have a good relationship with their neighbours. Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 12 Family members are made welcome at Firlawn and visit the home regularly; the manager said visiting times are flexible. Relatives are also invited to parties and barbecues at the home. A number of letters on file suggest that family members are happy with the care given to residents. Resident’s dietary needs are given priority as are risks to do with choking which is a significant concern at this home. Foods which represent a particular choking hazard are well documented and assessments from professionals give clear guidance to staff about what to avoid. Residents are given one to one support from staff during mealtimes. The menus were sampled and these are drawn up by staff with limited involvement from residents. The manager said staff have ascertained what residents like to eat and they have then planned the menus accordingly. Residents weights are monitored and their files showed they had been weighed every month since they first moved into the home. Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 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 and 20 Residents receive personal support in the way they prefer, and their emotional and health care needs are met. The administration of medication is well organised but further work needs to be done to meet this Standard in full. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans identify the help and support needed by residents with activities of daily living, and specialist assessments have been obtained. Care plans are reviewed on an annual basis so there is an up to date record of how resident’s needs have changed. Residents choose when to get up and go to bed and assistance with personal hygiene is available. This home has worked very hard to ascertain and mange the health needs of residents. Health needs and the support needed by each resident are very well documented and the home ensure any changes are monitored and reviewed by the appropriate community professional. Clear instructions are available to staff to assist them in supporting residents in relation to their health needs. The administration of medication is well organised at this home. Medication is securely stored, there were no excess medicines in the home, and medication Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 14 administration records were well kept. All staff who give medication have had some training but the medication training is currently given to staff by the manager who herself has not done a specialist training course for some time. The in-house training is based on a pharmacist’s training programme carried out in the home on 2004. The responsible individual said they had been considering outside training by a specialist pharmacy consultant. A requirement will be made that the home review their current arrangements for medication training. It was also noted that the pharmacy at this home has not been inspected by the community pharmacist, nor has their advice been sought, since 2004. The home must also review their arrangements for ‘as required’ medication as one resident was prescribed a painkiller to be given when necessary but there were no clear written instructions about the circumstances which might warrant this being administered. It was also noted that there was no list of staff signatures showing which staff could give medication. Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home have not received any complaints since the last inspection. The arrangements for protecting vulnerable adults at this home need to be reviewed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure at the home and it is translated into three different formats to suit residents needs. It contains details of the CSCI address and time limits for taking action. The complaints log was sampled and there have been no complaints since the last inspection. The home have received a number of commendations during this period. The home has a policy on the protection of vulnerable adults and the staff spoken to were clear about their responsibilities. The latest version of the Surrey multi-agency procedures for the protection of vulnerable adults is available in the home. However, not all staff were fully conversant with the policy on this matter, and the induction training did not confirm this either. The home needs to ensure that all staff have training and are knowledgeable about the home’s policy. In addition, one staff member was working without having been checked against the protection of vulnerable adults register; this could potentially place residents at risk. An Immediate Requirement was made on this matter and this is discussed later in the report. Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 16 Firlawn DS0000013642.V299472.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 and 30 Firlawn provides a very homely and comfortable environment for residents, and the standard of hygiene and cleanliness is good. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On arrival at this home the residents were away on holiday and due to return later in the day. The home was fragrant, and clean and tidy throughout. Firlawn offers a very homely environment which is kept well decorated and well maintained for the benefit of residents. Furnishings and fittings are domestic in character and there are many ‘homely’ touches including plenty of well cared for plants, two fish tanks and a variety of pictures around the home. There is a large living/dining room which leads out onto the garden, and an extra room for residents who wish to watch TV. The home and garden are fully accessible for residents Minor decorative matters which needed attention included a crack in the ceiling/wall join in the front bedroom, pipes which needed cleaning in the laundry, a window ledge needing repainting in the laundry, and a skirting board in a bedroom which was badly scuffed also needed attention. Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 18 The laundry room was also clean and tidy and a large commercial machine provides for washing at high temperatures. Systems are in place to control the spread of infection but on the day of the inspection a cotton towel was being used in a communal hand washing area. The manager removed this immediately. Firlawn DS0000013642.V299472.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): 32,33,34,35 and 36 Staff are competent to carry out their roles. Residents are not fully protected by the home’s recruitment practices. Staff induction and training needs more work in order to meet these Standards in full. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff interacted well with residents and were seen to be approachable and motivated. Out of the six permanent staff, two are registered nurses and one has an NVQ2 in care. Another has just completed an HND in health and care. The member of staff interviewed was enthusiastic about working with these particular residents and complimentary about the training and support offered by the manager and responsible individual. The manager said this staff member had not done any external training yet as she was completing her HND. Service users were being adequately supported on the day of the inspection but the inspector expressed concern about the practice of sometimes having one member of staff on duty in the home. The manager said this was because there are currently only two residents, and one is out on four days per week. However, given the concerns about health needs of residents, for example the risk of choking, the manager and responsible individual were asked to review Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 20 their current staffing levels. They said they were doing this already and were considering an extra member of staff being on duty. They were asked to obtain the Residential Forum Matrix to calculate staff to resident ratios, and to do a risk assessment regarding the current arrangements. They must also submit to CSCI a proposed staffing structure in relation to the new room which has been added. Four staff files were examined and a number of shortfalls were noted in recruitment procedures. • One had no application form • One had references but none from their last employer, even though this previous employment was in a care capacity and therefore the regulations set down a reference must be obtained. • Two had references from friends. • None of the files examined showed a full employment history as set down in the regulations. • One staff member had no CRB or POVAfirst check and an Immediate Requirement was made in this regard. • One had no record of an induction being in progress. These matters were discussed with the manager and responsible individual and suggestions made regarding rectifying the shortfalls. The person without a POVAfirst check must not work in the care home again until this has been obtained and this was agreed by Mr. and Mrs. Puah. There is evidence of some staff training at this home though the training and development plan is in its early stages and needs more work. Staff have an induction course though the items are merely listed and ticked, and then signed off by the manager or responsible individual – there was no way of checking from the induction record what had been covered under each heading. One staff member had ticked off that they had covered the protection of vulnerable adults, yet had not seen the home’s policy on this issue. Induction arrangements need to be reviewed to take into account the above comments, and the introduction of the common induction standards which will be mandatory from September 06. Another area of concern was that the manager and responsible individual were carrying out most of the training courses themselves, based on either purchasing external training packs or on training they have done themselves. This situation should be reviewed as discussed during the inspection. There was evidence from staff files that there was some staff supervision sessions but the manager could not demonstrate that six sessions per year, per member of the care staff, were being carried out and this needs to be rectified in order to meet this Standard in full. Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 21 Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Residents benefit from a well run home. Some quality assurance processes are in place but more needs to be done. Health and safety are taken seriously though further work needs to be done to meet this Standard in full. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is a trained nurse (RMN, RMNH) with a Diploma in Community Nursing. She has had twenty six years experience of managing and an NVQ4 qualification in management. Some of the management responsibilities (e.g. the budget) are shared with the responsible individual, Mr. Puah. The registered manager does refresher training herself from time to time and did health and safety training two years ago and first aid three years ago. There are some quality assurance systems in place including early work on an annual development plan and a staff development plan which were started last year. There is a monthly health and safety audit and a fire safety audit Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 23 including a monthly fire drill. There is a policy on quality assurance but the home is not currently following it closely. Also, the main contributors are Mr. and Mrs. Puah, and the manager of their third home; quality assurance work needs to involve other stakeholders, especially residents and staff. There are some comments on file from relatives but these are largely contained in thank you letters, rather than gathered systematically as part of an annual questionnaire for example. The responsible individual should review the current arrangements for quality assurance and ensure they are meeting all aspects of Standard 39. Health and safety is taken seriously at this home and a number of measures are already in place, including the monthly health and safety audit. Risk assessments identified particular areas of concern and there is clear guidance for staff on preventative measures. Areas needing review include legionella safety; there is currently no legionella safety certificate, nor clear guidance on this matter in the home. There is one shower head which is currently unused but no policy for how this should be managed, nor evidence of how legionella safety is being monitored. The home should take professional advice on this matter and ensure their policy is up to date and covers all possible areas of concern. The home does not have radiator covers in place and the radiators have adjustable thermostats. The radiators were not on whilst the inspection was being carried out as the weather was very warm. However, the responsible individual must carry out a risk assessment on the absence of radiator covers and then take action as suggested by that assessment. The National Minimum Standards and the Health and Safety Executive booklet ‘Health and Safety in Care Homes’ gives guidance on both radiators, and on legionella safety. The kitchen was generally very clean and tidy and there were instructions for staff on the cleaning regimes for worktops etc, and on the use of the colour coded chopping boards. The fire extinguisher on the wall had recently been serviced and the fridge temperature was with recommended limits. However, there were eggs in the fridge which were out of date and a number of items which had been opened but not labelled. The manager said as the residents were on holiday, she had not checked the fridge but would be removing the items above before their return. There were some finger lances for use in diabetic blood sugar tests, which had been left in the TV room cabinet and the manager agreed to store these more appropriately. Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X X 2 Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement There was no recent community pharmacist’s report and the responsible individual must contact the community pharmacist and make an arrangement for them to visit. The responsible individual must review the arrangements for ‘as required’ medication as discussed in the report. Clear written instructions must be devised for staff, in consultation with the prescriber. The current absence of a staff signature list should also be reviewed in relation to the administration of medication. The responsible individual must review the current arrangements for medication training as discussed in the report. The training and qualification of those delivering the training must be confirmed to CSCI. DS0000013642.V299472.R02.S.doc Timescale for action 09/07/06 2. YA20 13(2) 16/06/06 3. YA20 13(2) 09/07/06 Firlawn Version 5.2 Page 26 4. YA23 13(6) 5. YA24 23(2)(b) 6. YA30 13(3) 7. YA33 12(1)18(1)(a) The responsible individual must adopt a more robust procedure to ensure that all staff recieve training (including induction training) and guidance, on safeguarding vulnerable adults. The responsible individual must arrange to remedy the minor decorative matters which need attention: • The crack in the ceiling/wall joint, in the front bedroom • Pipes which need cleaning in the laundry room • The window ledge needs repairing and repainting in the laundry room • A skirting board in one bedroom is badly scuffed and needs redecoration. To reduce the risk of spreading infection, cotton (i.e. shared) towels must not be used in communal hand washing areas. Immediate. The responsible individual must ensure that the home is appropriately staffed at all times, and use the Residential Forum matrix and resident’s individual risk assessments to calculate staff to resident ratios. 16/06/06 09/08/06 09/06/06 10/06/06 8. YA34 19(1)(b) With reference to the 09/06/06 member of staff currently working without a CRB certificate or POVAFirst check:the registered person must take immediate action DS0000013642.V299472.R02.S.doc Version 5.2 Page 27 Firlawn 8. YA34 19(1)(a)(b)(c) 9. YA35 18(1)(a)(c)(i) 10. YA36 18(2)(a) to ensure the safety and protection of service users and provide CSCI, Eashing Office, with details of the measures taken. Immediate. The responsible individual 09/07/06 must not employ a person to work at the care home unless he has obtained the information and documents specified in paragraph 1-9 of Schedule 2 of The Care Homes Regulations 2001 as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004. This applies retrospectively and the above must be obtained for all existing members of staff. With regard to training, the 09/08/06 responsible individual must: • Complete the training and development plan • Review arrangements for induction as discussed in the report and during the inspection • Confirm to CSCI details of the qualifications and training of those delivering staff training at Firlawn. The registered person must 09/07/06 review the current arrangements for staff supervision to ensure that staff receive formal and documented supervision at least six times per year, and as set out in Standard 36. Version 5.2 Page 28 Firlawn DS0000013642.V299472.R02.S.doc 11. YA39 24(1)(a)(b) 24(2) The responsible individual must review the current arrangements for quality assurance and ensure the home is meeting all aspects of Standard 39. The responsible individual must carry out a risk assessment on the absence of radiator covers in the home. Following this, a plan of action on how service users will be safeguarded must be drawn up, with timescales, and sent to CSCI. The responsible individual must review the following as discussed at the inspection and detailed in the report: • Arrangements for storage of finger lances • Arrangements for legionella safety • Arrangements for the storage of food in the fridge and cupboards 09/08/06 12. YA42 13(4)(a)(c) 10/06/06 13. YA42 13(4)(a)(c) 10/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA33 Good Practice Recommendations A copy of the home’s Residential Forum matrix calculations should be sent to CSCI. Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Firlawn DS0000013642.V299472.R02.S.doc Version 5.2 Page 30 - 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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