Inspection on 15/07/05 for Five Ways

This inspection was carried out on 15th July 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Five Ways 19/06/09

Five Ways 20/06/07

Five Ways 12/06/06

Five Ways 02/12/05

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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Seabourne House

33 St John`s Church Road

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Lyncol House

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

CARE HOME ADULTS 18-65 Five Ways Kingsdown Park East Tankerton Whitstable Kent CT5 2DT Lead Inspector Jenny McGookin Unannounced 15/07/05 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 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 Stationary 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. Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Five Ways Address Kingsdown Park East, Tankerton, Whitstable, Kent, CT5 2DT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01227 277861 Adelaide Limited Mrs Paula Jane David Registered Care Home 3 Category(ies) of Care Home for Younger Adults (18-65) with a registration, with number Learning Disability, 3 of places Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Not Applicable Brief Description of the Service: Five Ways is registered to provide residential care for three adults with learning disabilities. The home caters for people of either sex, within the age range of 18-65 years. It is not wheelchair accessible and is not adapted for people with physical disabilities. The property is a spacious two-storey detached house in a quiet residential street in Tankerton. It has four spacious single bedrooms (one of which is for staff use), each with its own wash hand basin facilities. There are four communal WCs, three baths (one of which is also a Jacuzzi, though it is not currently in use) and two showers - all of which are conveniently located on the ground and first floors. The kitchen is on the ground floor along with the lounge, dining room, conservatory and a den (which is scheduled to be converted into a sensory room). The property has an enclosed garden to the rear, which has a patio area, and a swimming pool. The front of the property has been attractively landscaped. There is off road parking for two to three vehicles, and unrestricted kerb-side parking. There are bus routes at either end of the road. The home is within walking distance of shops and the sea front and is 5-10 minutes walk from Whitstable High Street, with all the transport and community resources that implies. Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which was intended to introduce the new inspector to the staff and the current resident; and to reach a preliminary view on the day-to day running of the home. There was one residents being accommodated by the home on the day of this inspection visit i.e. two vacancies, though there were two admissions in prospect. The inspection process took just under six and a half hours, and involved meetings with the manager, a senior support worker, support worker, the leisure activities co-ordinator, an advocate and a relative. The resident declined to meet with the inspector on this occasion. The inspection also involved an examination of records and the examination of the resident’s case file, to track his care. Three bedrooms on the first floor were inspected for compliance with the National Minimum Standards, and the inspector also checked all the communal areas. The resident did not want the inspector to assess his room on this occasion. Interactions between staff and residents were observed throughout the day. What the service does well: What has improved since the last inspection? What they could do better: The registered person must submit an up-to-date Statement of Purpose, Service User Guide and placement contract to the CSCI so that the inspector can judge their compliance with the National Minimum Standard and Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 6 regulations. The registered person must advise whether this is available in other formats. Some matters were raised for attention in respect of the provision of furniture and fittings in bedrooms, and communal areas, to obtain full compliance with the National Minimum Standards. Some areas require ongoing risk assessments, and precautions against the risk of accidents e.g. pool area and den. The washing machine will require a disinfecting or sluice cycle. All records and documents should be dated and authored. The challenge will be to demonstrate the active participation of residents in the home’s care planning processes. Input from the advocacy service will be instrumental to the success of this. 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. Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 1. Not all the documentary information necessary for potential residents to make an informed choice is available. 2. There is a systematic preadmission assessment process, which identifies needs, preferences and interests 3. This home accesses a range of social and healthcare professionals to ensure it maintains its capacity to meet the resident’s individual needs. 4. Prospective residents or their representatives have the opportunity to visit the home to assess the quality, facilities and suitability of the services it offers for themselves. The admission process also includes a flexible trial stay, before each admission is confirmed EVIDENCE: The homes Statement of Purpose, Service User Guide and placement contracts were not readily available, so the inspector was unable to judge whether they provided residents or their representatives with all the information they need to make a decision about moving into the home. However, records and anecdotal information confirmed that the decision to place the current resident in this home was based on comprehensive assessments, to ensure his needs could be met and his independence would be maximised and promoted. The resident’s relative and support workers spoke Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 9 enthusiastically about the positive changes they had seen in his social interactions, community presence and capacity to make decisions about his daily routines and activities. The relative confirmed he was able to visit the home before proceeding with the admission plans and there was a trial period before the admission was confirmed. Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8, 9, 10 6. The preadmission assessment and care planning processes cover a wide range of health and personal care needs, as well as some social care needs. Less clear, however, was the extent to which the current resident was involved in these processes. 7. The current resident was observed being supported to make decisions, and observed interactions between staff and the resident were respectful during this inspection. The home needs to take more control over the care plan reviews and demonstrate the active participation of the resident in this process. 8. The current resident has a number of opportunities to influence his daily routines and the running of the home, and his level of involvement is a matter of personal choice. 9. There are risk assessments to cover the resident as an individual, his activities and his environment (inside and outside the home), to maximise his capacity to be independent. 10. The arrangements for the storage and disclosure of confidential information is generally satisfactory, though some documents were not dated and it was not always clear who had produced them. Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 11 EVIDENCE: There was a range of preadmission assessments on file, which were in the first instance drawn up by the Joint Commissioning Learning Disabilities Team, or NHS Trust, then updated by the home’s own. The format of the care plan, which follows on is designed to address the health and social care needs of the resident, particularly when underpinned by documents such as a “Likes and Dislikes” document, signed by staff and the resident. Risk assessments are linked to the care planning process (daily living routines, behaviour management, safety in the community, finances) and subject to periodic reviews by staff at the home. The resident was observed being supported by staff to make his own daily living decisions. Less clear was the extent to which the resident is being actively engaged in the formal care plan reviews (though the senior support worker said the plans were shared with him), and how the home establishes the resident’s own perspective and any emerging unmet needs. The home does not appear to be recording its own reviews of care plan objectives, and appears to be overly reliant on the Care Managers to provide documentary evidence of formal review processes. The home needs to take more control over this process. Care plans should be summarised monthly so that progress and trends can be tracked by anyone authorised to inspect them. There was, moreover, scant evidence of policies being reproduced in accessible formats or plans to involve this resident being involved in the development of policies, staff recruitment or service development. The home’s arrangements for keeping confidential information secure against unauthorized access was satisfactory. Cabinets and office facilities are all properly secured. Some documents were not, however, dated and it was not always clear who had produced them. Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 15, 17 12. There is some choice and control over most aspects of daily routines. The current resident appears generally content with his lifestyles in this home, and the home has been able to match his expectations as interpreted by his representatives. 13. This home has a dedicated Leisure Activities Co-ordinator and offers a range of activities inside and outside the home. Links with the community are good and support and enrich Service Users social and educational opportunities. Activities are recorded. 15. There are open visiting arrangements, and the home is well placed for access to local community resources. 17. The meals in this home offer choice and variety and are catering for the resident’s needs and preferences. Meals are enjoyed, unhurried and the setting is congenial. EVIDENCE: Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 13 Abilities, activities and personal preferences are established as part of the preadmission assessment process, and confirmed by care plans and day-today consultation thereon. This home offers support to the current resident to maintain and develop his practical life skills, and the resident was observed being supported to make decisions and choices during the inspection visit. He is said to enjoy cooking and can manage pocket money with assistance. There are also developmental and recreational activities off site. The Leisure Activities Co-ordinator has been visiting the resident once or twice a week for about a year, and described how he was being supported on a computer course at the Umbrella Club and had learned how to use the Internet. He accesses the social groups run by the Umbrella and Gateway Clubs and has also joined a local gym and had also visited the Science and History Museum recently. He also has opportunities to access local mainstream community activities not confined to or identifiable with disabilities. The relative and support workers spoke enthusiastically about the way he was able to socialise and make and understand jokes. There are open visiting arrangements, confirmed by the relative, and there was anecdotal information on the extent to which staff support the current resident to maintain family links and friendships outside the home. There is one communal telephone in the den and there is also a phone lobby outside the utility room. The current service user is supported to manage a weekly phone card. Staff dial the number for him to use the phone. There is also a cordless handset which can be taken into other areas of the home for more privacy. Dietary needs and preferences are also established as part of the preadmission assessment process, and confirmed by the care plan and day-to-day consultation. There was anecdotal information to confirm that the current resident’s individual needs and preferences were being catered for. The dining area is a light spacious area which provides a congenial setting for meals but the resident can choose to eat elsewhere. Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 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 standard(s) 18, 19, 20 18, 19, 20. The current resident receives an appropriate level of support with his personal, emotional and healthcare needs. Personal care is offered in a way that protects his privacy and dignity and promotes his independence. 19, 20. The health needs of the current resident are well met with evidence of access to a range of healthcare services. Some matters were raised for attention in respect of the home’s medication recording system, to ensure the protection of residents. EVIDENCE: The preadmission and care planning processes assess the extent to which each resident can manage their own personal care, and their choice and control is actively promoted by staff. All the bedrooms are single occupancy and there are enough toilet and personal care facilities (baths, showers, wash hand basins) to guarantee their availability and privacy. Staff are available on a 24 hour basis to assist residents. The care planning process routinely addresses a range of standard healthcare needs e.g. GP, optician. The home also accesses care managers, psychiatrists and psychologists as appropriate. Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 15 The home has been working with its own medication administration arrangement and record system, but there were aspects of the record keeping which will require attention. The manager said the home will be adopting the monitored dosage system and medication administration recording system from Boots – which will be more robust. Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 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 standard(s) 23 23. The current resident is safeguarded against abuse. EVIDENCE: Staff induction covers a range of relevant policies: challenging behaviour; incident and accident recording; complaints; whistle-blowing; abuse and adult protection. In discussions with staff, they invariably confirmed their commitment to challenge and report any instances of abuse, should it occur. The rapport between staff and the current resident appeared appropriately familiar and respectful. The relative confirmed that he felt the resident was in safe hands, and said he felt confident that any issues raised with the manager would be acted on. Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 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 standard(s) 24, 25, 27, 28, 30 24, 28. The standard of the property is good. The furniture is domestic in style, and comfortable. Residents have a choice of communal areas, and there are homely touches throughout. Further investment is planned to make the home environment more safe and to install a sensory area, to enhance the resident’s lifestyle. 27. Each bedroom has a wash basin cubicle, and there are sufficient communal bath and WC facilities to guarantee their availability and privacy. 29. The home is not wheelchair accessible and although it has ample useable floor space throughout, it is not adapted for people with physical disabilities. 30. The home is well maintained, clean and free of offensive odours. Consideration must be given to providing an alternative route for access to the ground floor WC/bathroom. EVIDENCE: The layout of this home is generally suitable for its registered purpose. With the exception of one bedroom, all areas of the home were inspected and found to be homely, comfortable and clean. The furniture tends to be domestic in Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 18 style and there were homely touches throughout. The rear garden, although monopolised by the swimming pool and patio, provide pleasant discrete focal points and congenial areas to walk or sit in. The home has a “No Smoking” policy. Communal Areas These are all on the ground floor. There is a spacious formal lounge at the front of the home, with a split level “den” (which is scheduled to be converted into a sensory area) forming a discrete room at its far end. The dining room is at the centre of the home and is linked on one side to the kitchen and at its far end to the conservatory and rear garden. All the chairs (dining, lounge and conservatory) belong to suites and are therefore uniform in style – a range of chairs (e.g. some with arms, or set at different heights) would give residents more choice. Because of identified trip / accident hazards, much of the stonework and sharp edging (in the den area in particular, where there is a split level well) are scheduled for removal or cushioning, but there was no timeframe for this. The kitchen is light, airy, clean and well maintained. Communal Bathrooms / WCs On the ground floor there is one WC / basin; one WC/shower and one bath/Jacuzzi (though this is not currently being used). On the 1st Floor there is one bath / WC / shower / sink; one bath (with shower attachment) and WC i.e. all facilities are reasonably accessible to bedrooms and communal areas. The 1st floor bathroom /WC / shower room are carpeted. This is not a hygienic arrangement. Some tiling work required repair, replacement or re-sealing along edges, to obtain continuous impervious surfaces, capable of being cleaned easily. Some matters were raised for attention. Bedrooms All the bedrooms are spacious and single occupancy. The resident did not want his bedroom inspected on this occasion. All the other bedrooms were inspected and found to be well maintained. In terms of their furniture and fittings, they were generally compliant with the provisions of the National Minimum Standards, but some elements were identified for inclusion. Every bedroom also has a TV point Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 31. Each personnel file has a Job Description, Person Specification and Contract, to clarify staff roles and responsibilities. 32. Staff are suitably invested in, in terms of training opportunities and supervision, and gave a number of examples of the way they positively promoted the resident’s quality of life. 33. There was compliance with the staffing levels as described on the day of this inspection, and there is some flexibility over shift arrangements to allow staff time out without compromising staffing levels in the home. Team working and support for the resident were identified as a key strength. 34, 36. The service users are safeguarded by recruitment processes, training and supervision EVIDENCE: The manager described the following staffing arrangements. From 10am on Mondays till 10am on Thursdays, one support worker works from 10am till 10pm (including sleep in on-call night duty). From 10am on Thursdays till 1oam on Mondays (10am) – a second support worker works from 10am till 10pm (including sleep in on-call night duty). There are no dedicated ancillary staff (e.g. cooks or cleaners). The current resident is supported to carry out some domestic chores. This arrangement is Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 20 said to suit both staff, though sometimes they cover for each other on Sundays to allow the other time out. Once or twice a week there is also a Leisure Activities Co-ordinator. There was compliance with these staffing levels as described on the day of this inspection, although staffing rotas were not analysed on this occasion. The manager was advised to include a legend on staffing rotas to explain any codes used; to detail her own on-site hours; and to record ancillary hours (cooking and cleaning) separately, where staff duties are split between direct care tasks and ancillary work so that anyone authorised to inspect the records can readily evaluate the staffing arrangements. Staffing rotas will be assessed at the announced inspection. An examination of personnel files corroborated information supplied by staff. All personnel files were in good order and provided good evidence of a systematic approach to recruitment, induction and training. There is induction programme to cover a range of issues: the organisational arrangements; health and safety; residents’ issues (special needs, medication, personal care, challenging behaviour and care plans / programmes); administrative tasks and work practices. This period is also used to identify further training needs. Each personnel file included a training record (which included TOPSS training), and copies of resultant certificates. Staff confirmed having had a range of training opportunities, such as food safety, fire safety, manual handling, First Aid, challenging behaviour. All the staff who met with the inspector confirmed that they had regular formal supervision from their line manager, though the frequency of this did not in all cases comply with the National Minimum Standards. The line management was said to be accessible and supportive. Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 42 37, 42. The Home is well managed, and actively supports the resident’s independence, health, safety and welfare. EVIDENCE: The registered manager has had several years’ experience in the residential care sector, and has a good relationship with staff, the resident and his relative. Some matters were raised for attention in respect of aspects of the record keeping (most notably, dating, authorship) but they were in the main judged in good order and maintained in the best interests of the resident. Fire safety maintenance checks were found to be up to date and weekly petty cash accounts and financial records were judged fully accountable and properly supported by receipts. The home has the required public liability insurance cover. Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 2 3 2 Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 3 3 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 N/A 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Five Ways Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 x H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 23 N/A 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 YA1.1 Regulation 4& Schedule 1 Requirement The registered person must submit an up-to-date Statement of Purpose to the CSCI so that the inspector can judge its compliance with the National Minimum Standard and regulations. The registered person must advise whether this is available in other formats. The registered person must submit an up-to-date Service User Guide to the CSCI so that the inspector can judge its compliance with the National Minimum Standard and regulations. The registered person must advise whether this is available in other formats. The registered person must maintain copies of its Statement of Purpose, Service User Guide and placement contract on site so that prospective service users have all the information they need to make a decision to proceed with admissions The registered person must submit an up-to-date Placement Contract to the CSCI so that the inspector can judge its compliance with the National Timescale for action 30 09 05 2. YA1.2 5 30 09 05 3. YA1 4, 5 Immediate and ongoing 4. YA5 5(b)(c) 30 09 05 Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 24 5. YA20 13(2) 6. YA24 13(4)(a) 7. YA26.2 16 8. 9. 10. YA26.2 YA26.4 YA26.4 16 216 16 11. YA27 13(4)(a) Minimum Standard and regulations. The registered person must advise whether this is available in other formats. Medication Arrangements. The following matters are raised for attention: The home needs to obtain a copy of The Royal Pharmaceutical Society of Great Britains guidance on The Administration and Control of Medecines in Care Homes and Childrens Services and check compliance. Medication Administration Record (MAR) charts must show the full initials of staff administering medication, so that there is no confusion with codes used to indicate irregularities. The allergies section on MAR charts needs to be detailed or marked non known / applicable. Little Den - Need to risk assess two steps into well area, stonework pending its removal (already scheduled) sharp edges scheduled to be padded Bedrooms. The folowing matters are raised for attention: Each bedroom needs to have the equivalent of two double sockets. Each bedroom should have a table to sit at Each bedroom needs to have a lockable space. Standard locks on bedroom doors should be replaced by double acting locks, accessible from the outside in an emergency. WC / bathroom areas. The following matters are raised for attention: Need to risk assess towel rails on radiators as could be 30 09 05 Immediate and ongoing 31`12 05 31 12 05 31 12 05 31 12 05 30 09 05 Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 25 misinterpreted as grab rails. 12. YA27 23(2)(j) Bathroom / WC doors must have double acting locks accessible from the outside in an emergency. Carpeted flooring is not judged a hygienic arrangement for WC or bathroom facilities. Some bathroom tiles were missing or damaged and seals on edges of some wall sections were coming adrift. Kitchen. There need to be fly screens on windows or an insectocutor needs to be installed. Laundry. All surfaces (walls, flooring and shelves) should be smooth, impervious and easily cleaned. Laundry. Exposed pipe-work for the Jacuzzi should be boxed in so as not to create a dirt trap. 31 12 05 13. 14. YA27 YA27 13(3) 13(3) 30 10 05 30 10 05 15. YA28 13(4) 31 12 05 16. YA30 13(3) 31 12 05 17. 18. 19. 20. YA30 13(3) 31 12 05 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. Refer to Standard YA7 YA10 YA30 Good Practice Recommendations The home needs to take more control over the care plan reviews and demonstrate the active participation of the resident in this process. Documents should always be dated to demonstrate their currency, and it should always be clear who had produced them. Kitchen. Recommend sluice or drain is used to dispose of water used for cleaning. 1st Aid kit requires blue plasters, eye pads with attachments, safety pins - recommend a check list for stock control· Staff lockers are recommended for the staff room. H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 26 4. YA28 Five Ways 5. YA27 Lighting should be regularly checked and exposed wiring in one room will require attention. External bathroom windows should have blinds or curtains to guarantee privacy and provide homely touches. Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Five Ways H56-H05 S47387 Five Ways V236413 150705 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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