Inspection on 04/04/07 for Fouracres Care Services

This inspection was carried out on 4th April 2007.

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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fouracres Care Services 04/05/06

Fouracres Care Services 16/01/06

Fouracres Care Services 19/05/05

Fouracres Care Services 14/02/05

Fouracres Care Services 26/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Fouracres Care Services 47 Fouracres Enfield Middlesex EN3 5DR Lead Inspector Jane Ray Key Unannounced Inspection 4th April 2007 09:30 Fouracres Care Services DS0000053227.V333004.R01.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 Fouracres Care Services DS0000053227.V333004.R01.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. Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fouracres Care Services Address 47 Fouracres Enfield Middlesex EN3 5DR 020 8292 4823 020 8216 1306 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) Mrs Philomena Chikwendu Okoron-Kwo ** Post Vacant *** Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home must not admit anyone with a physical disability who is unable to descend the stairs without assistance in the event of an emergency. The home is not suitable for wheelchair users. Service users should not be allowed in the office in the loft room. The registered persons must ensure that an appropriate balance of female and male staff is maintained to reflect the gender of the service users. 5th October 2006 Date of last inspection Brief Description of the Service: Fouracres is a small home registered to provide a service to four service users who have a learning disability. Ms Philomena Chickwendu Okoron-Kwo owns the service. At the time of the inspection the registered manager post was vacant with a manager coming into post. The service is an end of terrace house with three floors. The ground floor consists of a kitchen, lounge/dining area and one bedroom. On the first floor there are three further bedrooms and an office/sleep-in room. On the top floor in a loft conversion there is an office area. The home is located in a quiet residential area of Enfield and is a short distance from local shops and public transport. The stated aims of the home are to provide support to people with special needs in a safe and secure environment’. The weekly fees in the home range from £850 to £1866 per week. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 4 April 2007 and was unannounced. The inspection lasted for three and a half hours. The inspection was the main annual inspection and looked at how the service was performing in terms of meeting the key National Minimum Standards for Younger Adults and the associated regulations. The inspector was able to meet and spend time speaking to the three current service users. The inspector as part of the inspection was able to meet and speak to the registered provider and two care workers. The inspector did a tour of the premises and also looked at the service user case notes, staff records and other health and safety documentation. What the service does well: Two service users were able to tell the inspector that they like the home and that the staff are nice. The home provides a good standard of care and support to a group of service users with a range of complex needs. Service users are supported by the staff to access members of the multidisciplinary team to ensure their personal care, social and emotional health needs are met. The staff team is stable and staff demonstrate a good knowledge of the service users and are able to recognise their individual needs. The service users are supported to have their individual needs met by a key working and care planning system. The service users are offered access a range of structured activities that they said they really enjoyed. The service users said they enjoyed the food. The home is comfortable and homely and the service users each have a single bedroom that is personalised to their taste. Service users are supported to maintain positive contact with their relatives. Service users are supported to practice their religion in line with their personal wishes. Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 6 The service users are protected and supported by the effective use of policies and procedures including medication systems, adult protection procedures, comprehensive environmental risk assessments and health and safety procedures. What has improved since the last inspection? What they could do better: Seven requirements have been made at this inspection of which three are restated from the previous inspection. One requirement was made under the section choice of home and this was for the service to update the service user assessments. One requirement was made under the heading individual needs and choices. This was to ensure each service user has a record of how they are supported to manage their personal finances. It was also recommended that review meetings are arranged with each service users care manager as it is nearly a year since some of these meetings last took place. It was also recommended that the risk assessment documentation is reviewed so that they are all recorded on the same format and are easier for the staff to follow. Two recommendations were made under the heading of lifestyle to support service users to access a wider range of leisure activities in line with their personal interests and to support one service user to get advice and support to make progress towards his personal goal of gaining employment. Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 7 A recommendation was made under the heading of personal and healthcare to place a copy of the service user PRN medication guidelines in the medication folder so staff can easily access this information. A requirement was made in the section concerns, complaints and protection to display a user-friendly complaints procedure. In the section on staffing two requirements were made to amend an incorrect CRB disclosure and to book a training programme for the coming year. Two requirements were made in the section called conduct and management of the home to ensure the newly appointed manager completes the registration process and to complete monthly regulation 26 monitoring visits and send copies of the reports to the CSCI. 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. The summary of this inspection report can be made available in other formats on request. Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 8 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 Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2,3 and 4 were inspected. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users can be sure that the home will endeavour to meet their individual needs and that they can visit the home as part of the process of deciding if they want to live there. Service users currently living in the home do need to have their assessments updated. EVIDENCE: The three service user case notes were inspected. They all contained records of the assessment provided by the care manager to the home as part of the service users admission process. Two of the service users have been living in the home for nearly two years. They would benefit from have an updated assessment prepared by the service. Whilst some assessment information is provided as part of the care plans these records also need to be updated to reflect changes that have taken place. Two of the service users were able to tell the inspector how they had visited the home before they moved in as part of the process of establishing if they Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 10 wanted to live in the service. One service user said she visited with her relatives and the other service user said he made a number of visits. The service aims to meet the religious and cultural needs of the service users. One service user is a practicing Muslim and the staff work closely in partnership with her relatives to support to access a place of worship, wear appropriate clothing, eat the correct food and maintain appropriate standards of modesty. Two service users had told the inspector at the previous inspection that they were finding it very difficult to live with a service user whose behaviours were making them very upset. This service user is no longer living in the home and the service users said they were getting on well with each other. Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7,8, and 9 were inspected. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users have individual care plans and risk assessments and are supported by a member of staff who acts as their key-worker. They are also enabled to have an active role in making decisions about their care and the operation of the home. Service users need to have an accurate record of how they are supported to manage their personal finances and who acts as their appointee. EVIDENCE: The case notes were inspected for the three service users. They all had comprehensive care plans that related to all aspects of their lives. These care plans had been reviewed in the last month. Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 12 The service users all have a key-worker and two of the service users were able to tell the inspector the name of their key-worker and what they enjoyed doing on their allocated key-worker days. All of the service users have complex behaviours and written guidelines are in place for each service user as a separate document or as part of their care plan on how staff should support them with these behaviours. All the service users have had reviews with their care manager in the past year and the actions from these meetings have been incorporated into their care plans. One service user said her care manager had left his job and she was not sure of the name of her new care manager. It is recommended that review dates are arranged with the care managers for the next review meeting. All the service users have risk assessments. These are available on more than one format that makes them hard to follow. It is recommended that the risk assessments are updated and recorded on one format. The risk assessments record any restrictions and why they are in place. For example one service user has his cigarettes and lighter held by the staff for safety reasons. A service user has a programme in place to help him budget his money and from discussions and looking at records the inspector could see that the service user had been actively involved in agreeing this programme. Each service users care plan contains a section on finances. For one service user there was not an accurate record of who acts as her appointee and who holds her building society book. It is required that each service user has an accurate record of how they are supported to manage their personal finances and this includes who acts as their appointee. Service users were observed making decisions about their daily lives in the home including what to eat, when to go out and what to wear. Service user meetings have been taking place on a monthly basis and the records were inspected. The service users said they talked about a number of things including activities, holidays and food. Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11,12,13,14,15,16 and 17 were inspected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are supported to enjoy an active lifestyle and to maintain contact with their relatives. They are also supported to have a nutritious diet. There is scope to support a service user to make progress towards employment. EVIDENCE: Service users told the inspector that they were actively involved in helping with domestic activities in the home such as doing their laundry, tidying their room and helping to prepare food. Service users were observed preparing snacks and drinks. The service users have care plans in place to reflect their individual goals of developing their independent living skills. Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 14 The inspector spoke to two of the service users and also looked at the individual activity records. These showed that service users have been supported to participate in a range of activities and educational opportunities. One service user is on a waiting list for a place at an Enfield centre but has continued her previous placement in Islington until the place becomes available. Another service user said he really enjoys his two college courses where he does gardening and IT. He did however say that he wanted to make progress with obtaining employment and it is recommended that steps are taken to support him with this goal. One service user goes to an Asian Centre on a weekly basis, which she said she really enjoys. It is positive that the service user activity programmes are reviewed on a weekly basis in partnership with the service users. The record of activities was inspected. It was noted that during their spare time the service users spend lots of time with relatives and that other leisure activities are quite limited. It is recommended that the service users are supported to enjoy a wider range of activities in line with their individual interests. Two service users enjoyed a holiday last year at Hastings and plans are being made for a break this year. The service users all have individual arrangements in place for maintaining contact with their relatives. The service can help the service users visit their relatives if this assistance is required. It was observed during the inspection that the service users are supported to follow their own routine and service users can for example choose to have a lie in if they do not need to get to an activity or appointment. It was also observed that the service users feel relaxed about spending time in their bedrooms or in the communal areas of the home. One service user said “I get up and go to bed when I want to and I like to watch TV in my bedroom”. Two service users said the food was really good. The record of food consumed was completed and the inspector could establish that the food was healthy and nutritious. There was plenty of fresh fruit and vegetables in the house. It was also observed that the kitchen was clean and tidy and that health and safety measures such as checking the fridge temperature were in place. Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20 were inspected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are supported to access input as required from healthcare professionals. The service users are supported to receive the correct medication through the appropriate use of the medication system in the home. EVIDENCE: The inspector observed the service users being discreetly supported in aspects of their personal care. The service users all looked well presented and their clothing reflects their individual style and culture. The service users were able to tell the inspector how they buy their clothes or access the hairdresser. The healthcare records were inspected for each service user. It was positive to see that they had all accessed the primary healthcare checks with the GP, dentist and optician. In addition they were supported to access specialist services according to their individual needs. This included attending a diabetes Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 16 clinic and also receiving input from the psychiatrist. One service user has an ongoing cough and this is being investigated. The medication in the home was inspected. The service uses the Boots blister pack system. The medication administration records are correctly completed. The medication entering the home and being returned to the pharmacist is recorded. None of the service users self-administer medication. The medication is stored in a medication cupboard and the temperature is recorded on a daily basis. The training records were inspected for four members of staff and they had all received medication training. One service user has PRN medication but the administration guidelines were not in the medication folder but in his care plan folder. It is recommended that these guidelines are placed in the medication folder for ease of access. Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were inspected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a complaints record but a user-friendly copy of the complaints procedure should be displayed. The appropriate procedures and training are in place to protect the service users from abuse. EVIDENCE: The complaints record was inspected and there have been no complaints received in the last six months. The complaints procedure has been made available to the service users in the service user guide and a user–friendly procedure is also available but needs to be displayed in an area accessible to the service users. Two service users when asked said they would be happy to talk to the staff or the manager if they had any concerns. The training records were inspected for four members of staff and they had all received training on how to support people with challenging behaviours and the protection of vulnerable adults. The finance records were inspected for one service user. These showed all expenditure and receipts were available. Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,25 and 30 were inspected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service users are able to live in a clean and homely environment. EVIDENCE: The inspector did a tour of the communal areas of the home. The home was appropriately heated and was clean and tidy throughout. Antibacterial soap and hand-towels were available in the shared toilets. The inspector was invited by two service users to look at their bedrooms and these were comfortable and personalized. The inspector observed that in a few areas the decoration needed some repairs such as borders coming off the wall but the registered provider explained that decoration was taking place on an ongoing basis. The furniture was all in a good state of repair. Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 19 The inspector observed that there was no downstairs toilet, which can be difficult for the service users who use the stairs slowly. It is recommended that a downstairs toilet is installed. Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34,35 and 36 were inspected. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The service users are supported by a small and stable team of staff. Recruitment procedures are in place to safeguard the service users. Staff have a record of training but an ongoing training programme to ensure good standards of care needs to be booked. EVIDENCE: The inspector looked at the staff rota. There has been one new care worker appointed since the last key inspection. Two staff are on duty during the day if there are three service users in the home and there is one member of staff if there are only two service users. At night one member of staff sleeps in the home. From the rota it was observed that regular staff are able to cover all the shifts. The staff team is currently small with six permanent and one very part-time member of staff. Four are doing NVQ training in care through different colleges Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 21 and so 50 are undertaking the training. Letters confirming this training is taking place are in the staff training records. The staff meetings records were inspected and these meetings have been taking place on a monthly basis and discuss a wide range of operational issues. Four staff recruitment records were inspected. All the staff had an application form, two references, a CRB disclosure, copy of their ID and a visa where required. The most recently recruited member of staff has an error on her CRB as the agency who act as the umbrella organisation for the completion of the CRB is recorded as the employer and not Fouracres and this needs to be amended. The staff contracts were inspected and they included information such as contracted hours and hourly rate of pay The staff have all got a completed induction record. Staff all have a record of the training they have received. Work has started on an ongoing training plan but this needs to be further developed with training dates agreed and trainers booked. The staff supervision records were inspected for four staff and they had all been supported to receive regular individual supervision. Fouracres Care Services DS0000053227.V333004.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42 were inspected. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The service users can be assured that health and safety measures are being implemented in the home. They have also been able to contribute their views through the quality assurance work. A permanent manager who has completed the registration process is needed to maintain standards for the service. EVIDENCE: The inspector had been informed after the last key inspection in October 2006 that a permanent manager had been appointed. The inspector had then been Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 23 contacted shortly prior to this inspection to say that he had been offered the post of manager at Fouracres. At the inspection the registered provider explained that the previous manager had not been able to remain in post and that it had been an oversight not to inform the CSCI. The newly appointed manager is however due to come into post at the end of April 2007 but still needs to complete the registration process. The quality assurance audit and action plan was observed and has been completed. The inspector noted that since the previous key inspection she has not received regulation 26 registered provider monitoring reports. The training records were inspected for four staff. They had all received training on food hygiene, first aid and fire safety with the exception of the newly recruited member of staff. The fire safety records were inspected. The smoke detectors are being checked weekly and fire drills take place monthly. The service users confirmed that they participate in fire drills. A fire safety risk assessment and emergency plan has been completed. Health and safety risk assessments are in place for the house and a weekly health and safety check takes place. Certificates are available to confirm the electrical installations, electrical equipment, gas system and fire appliances have been serviced. Incident records were inspected in the service users case notes and were appropriately completed. The insurance certificate for the service was inspected and was satisfactory. Fouracres Care Services DS0000053227.V333004.R01.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 2 3 3 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 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 3 x Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 YA2 Regulation 14(2) Requirement The registered person must ensure that the service users have an updated assessment completed by the home. The registered person must ensure that each service user has an accurate record of how they are supported to manage their finances including who acts as their appointee. The registered person must ensure a user-friendly complaints procedure is displayed in the home. This requirement is restated from the previous inspection. The timescale of 31/10/06 was unmet. The registered person must ensure that the staff member with the incorrect CRB disclosure has the error rectified. The registered person must ensure that the training programme for the next 12 months is booked with the training provider. This requirement is restated from the previous inspection. The timescale of 31/10/06 was DS0000053227.V333004.R01.S.doc Timescale for action 30/06/07 2. YA7 12(1) 31/05/07 3. YA22 22(2) 31/05/07 4. YA34 19(1)-(5) 31/05/07 5. YA35 18(1)(c) 30/06/07 Fouracres Care Services Version 5.2 Page 26 unmet. 6. YA37 8(1)(2) The registered person must ensure a manager is in post who can complete the registration process. This requirement is restated from the previous inspection. The timescale of 31/10/06 was unmet. The registered person must ensure the monthly regulation 26 monitoring visits are completed and a record sent to the CSCI. 30/06/07 7. YA39 26 31/05/07 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. 5. 6. Refer to Standard YA6 YA9 YA12 YA12 YA20 YA27 Good Practice Recommendations The registered provider should arrange review dates with the care managers for each service user. The registered provider should review the risk assessments so they are all recorded on the same format and are easier for staff to follow. The registered person should support the service user who wants to have a job to start accessing support to prepare him for future potential employment. The registered person should support the service users to participate in a wider range of leisure activities in line with their individual interests. The registered person should place a copy of each service users PRN medication guidelines in the medication folder. The registered person should provide a downstairs toilet in the home. Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Fouracres Care Services DS0000053227.V333004.R01.S.doc Version 5.2 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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