Inspection on 08/01/06 for Foxlydiate Mews, 1

This inspection was carried out on 8th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Foxlydiate Mews, 1 09/12/06

Foxlydiate Mews, 1 15/07/05

Foxlydiate Mews, 1 21/12/04

Foxlydiate Mews, 1 08/09/04

Foxlydiate Mews, 1 30/03/04

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Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Foxlydiate Mews, 1 1 Foxlydiate Mews, Lock Close Batchley Redditch Worcestershire B97 5LQ Lead Inspector P Wells Unannounced Inspection 8 & 12 January 2006 11:00 th th Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Foxlydiate Mews, 1 Address 1 Foxlydiate Mews, Lock Close Batchley Redditch Worcestershire B97 5LQ 01527 60482 01527 61840 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) www.hft.org.uk Home Farm Trust Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is primarily for people who have a learning disability but may also have an associated physical disability. 15th July 2005 Date of last inspection Brief Description of the Service: 1 Foxlydiate Mews is a modern, purpose built establishment in a residential area of Redditch, Worcestershire. The property is close to the town centre. The house and grounds are owned by Bourneville Village Trust, who lease it to Worcestershire County Council (WCC Social Services). Home Farm Trust (HFT) are contracted by WCC to provide the service. The home provides a respite care service for younger adults who have a learning disability and some of whom may have a physical disability. The main aim of the service is to offer planned respite care for up to five individuals between the ages of 18 – 65. The home aims to promote a philosophy of care that recognises and responds to the individual rights and needs of service users. The manager and staff also provide a service to five tenants living in houses in Foxlydiate Mews. The registered providers are Home Farm Trust Limited, (HFT), whose head office is in Bristol. HFT provide care services nationally to individuals with learning disabilities and their families. The responsible individual is Mrs Mina Malpass. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection that took place during Sunday 8th January 2006. Time was spent preparing for the inspection and five hours at the home. The service offers planned short stays to 27 guests and all the places are funded by Worcestershire Social Services. Four of the places are for planned stays and the fifth place for emergencies. The service is open 51 weeks of the year and had been closed over the christmas period. The registered manager had resigned in mid December 2005 and a meeting was held on 3rd January 2006 with Mrs Jeanette Rix, service manager and Mrs Audrey Rowley,assistant service manager, to hear the interim proposals for managing the home. HFT will be advertising for a manager. Until 1st March 2006, the senior support worker will be full time acting manager with the support of the assitant service manager who wil be based at the home three days a week. At the week-end visit, time was spent with the five guests, staff, viewing the home, observing and reading documentation. The second visit was to meet with the acting manager and assitant service manager to discuss how the service would be developed, the previous requirements and recommendations, and staffing. The managers explained that the service was set up for guests with a mild to moderate learning disabilty, who may also have a physical disabilty. However it was apparent from these visits, and the managers confirmed, that guests needs were often more complex. This report should be read alongside the previous report of the visits to the home in July 2005. The pharmacist inspector also visited in August 2005 to view the medication system and her findings were sent in a letter to the home. The inspector appreciated the welcome, co-operation and time of the guests, staff and managers. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5 The service has information about the service for prospective guests and their representatives but it needs to be updated. The introductory process is service user led and relevant information obtained to ensure that the needs of an individual can be met. The service needs a statement of terms and conditions. EVIDENCE: The home had a combined statement of purpose and service user guide, which was written for prospective guests’ families and carers. A service user showed the inspector this document and it was pleasing to see it was in regular use and accessible. However it still needed to be reviewed to include all points listed in the standard, Regulations 4,5 and Schedule 1 of The Care Homes Regulations, and updated with changes of some persons’ names. The assistant service manager agreed to do this. Consideration should be given to the service user guide being in different formats for the guests. Two prospective guests were being introduced to the service. Their files were viewed and it was apparent that for both, assessments from social workers were obtained and planned introductions were arranged. Only one had a completed HFT assessment. At these visits the emergency place was being used by a tenant from the nearby supported living accommodation because the heating was not working Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 9 in the bungalow. This person was enjoying the company of others and they knew each other (guests and staff). The service does not have an agreement/statement of terms and conditions. This needs to be introduced for the guests and their families/carers. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,9,10 Information is kept to ensure that the guests’ assessed needs are known to the staff and consistent care is provided. The risk assessments still need to be developed to cover all risky situations. The acting manager immediately took action to ensure the guests’ personal files are kept in a locked place. EVIDENCE: The sample of two service user plans viewed indicated that there was a clear picture of the individual needs of the guests and how staff should assist them. Each guest had a care book (detailing their daily routines) and a communication book (between home/the service/day placement). The HFT forms had not been used but nevertheless there were care and support plans in place. Also an admission form was completed by the families/carers for each admission so that the home had up to date information relating to medication, clothing, personal belongings and monies. Some reviews were recorded but it was unclear whether there is a formal process for reviewing the service user plans six monthly, or when needs change, with the guest and their representatives. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 11 The risk assessments had been reviewed but in some areas could be developed, as previously suggested. The assistant service manager agreed that this would be completed by herself and the acting manager within the next month or as guests were admitted. The guests’ files were still being stored on a shelf in the office with the door left open. The acting manager arranged for the hook on the office door (a fire door) to be removed by 13.01.06 and to give instructions that the office door was to be kept shut and locked when not in use. This would mean that the guests’ records were being kept securely and that the fire door was not left open inappropriately. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standards 12-16 were previously met and not fully assessed on this occasion. However the following was observed: The guests, with differing levels of ability were contentedly pursuing their own interests on the Sunday morning – having a lie-in, choosing and watching videos, playing indoor cricket, listening to music and one service user was doing crosswords. Staff were interacting with the service users and there was a relaxed atmosphere. A full roast lunch was being prepared and welcomed by all the guests. Drinks, fruit and snacks were readily available as well as late breakfasts. The previous requirement regarding the staff completing food hygiene training had not been implemented. The assistant service manager was following this up. The previous recommendation regarding the service having it’s own transport was discussed with the managers. It was explained that this would be too costly for HFT to fund. Consideration could be given to ascertaining whether a Social Services minibus could be used at weekends. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 13 Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20 The guests receive appropriate support with their personal and health care, which is outlined in their service user plans. Staff need training on diabetes from a health care professional. Improvements need to be made to the storage and record keeping of medicines. EVIDENCE: Standards 18 & 19 were previously met and not fully assessed on this occasion. However the following was observed: The personal and health care needs of the guests staying were known to the staff and outlined in their service user plans. Personal care was provided discreetly by staff. Staff had received refresher training in administering an invasive treatment for epilepsy. A guest staying needed treatment for diabetes and it was arranged for the nurse to visit daily. Staff were taking and recording blood sugars but there was no written guidance about this procedure nor had the staff received training from a health care professional. The number of times the blood sugars were taken daily varied in the service user plan to the current practice and this needed clarification. Staff had learnt from each other how to proceed. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 15 Nevertheless they were clear that if a problem arose they could discuss it with the visiting nurse and had an emergency contact number for the nurses. The Worcestershire Health Action Plans would be beneficial for guests to bring with them for their short stays. This has been raised with the Social Services residential services manager (learning disabilities). The acting manager of the service agreed to ascertain whether any of the guests had health action plans. The medication system had been inspected by the pharmacist inspector in August 2005 and her findings, requirements and recommendations had been sent to the home in a letter. The requirements and recommendations need to be implemented and a copy of the letter has been sent to the acting manager. A medication error had been investigated and addressed by HFT. HFT were implementing named staff on each shift to take the lead for administering the guests’ medicines. Also a medication refresher course was being arranged. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but the following was noted: The home had a suitable complaints procedure and it was produced in a format more suitable for the service users. A file to record complaints had been introduced and needed further development, which the assistant service manager was going to action with HFT forms. Any complaints are investigated by HFT and addressed. The home has suitable procedures in place for the protection of vulnerable adults, the Worcestershire guidance for staff, and a system for the recording and checking of service users’ monies handled by staff. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The house was homely, comfortable, clean and well maintained for the guests to live in. The rooms, space, facilities and equipment were suitable for the guests using the service. The problems with the heating and hot water system need addressing. EVIDENCE: These standards were fully assessed at the last inspection. See the previous report for details of the accommodation. On this occasion it was noted that: At the first visit, the heating and hot water system had broken down and the contractors had been called. The home had free standing heaters and had boiled water for personal washing. The communal rooms were an acceptable temperature. It was commendable how staff were coping with this difficult situation. The inspector was advised that the system was repaired during the afternoon of 8th January 2005 and the home was a suitable temperature at the visit on 12th January 2005. The system had broken down in December 2005 and the hot water supply has been inadequate for sometime. These issues need addressing with Bournville Village Trust to ensure the heating and hot water system is effective at all times. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 18 The home was clean, maintained, safe, and bright. The guests showed the inspector around the home and their bedrooms. The rooms were suitably furnished and bedrooms colour coded for easy reference. Whenever possible the guests have the same bedroom for their stays. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35,36 The guests are supported and cared for by a suitable number of staff, the majority of whom know the guests and are experienced. There needs to be a settled, permanent staff group who are supervised regularly. A 2006 training programme for staff needs to be introduced. EVIDENCE: The staffing situation was discussed in detail. The assistant service manager had carried out a review of the staffing arrangements and was proposing new rotas from 1st February 2006, separating the staffing of the home from the staffing of the supported living accommodation. Current and draft new rotas were available. The staff group for the home will be small and is dependant on a senior support worker being appointed to support the acting manager. There is a bank of relief staff, which are regularly used. The staff on duty were experienced and clear about their roles and responsibilities. They were supportive of the temporary management arrangements for the home but concerned that staff were leaving and that the home did not have a settled, permanent staff group. HFT were ensuring there were sufficient staff on duty to meet the individual needs of the guests staying at any one time. A minimum of two staff are on duty and often three/four staff. This was evidenced at the visits. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 20 The training details for staff were not available and the inspector was advised that these details had been sent to HFT Training Co-ordinator to be appraised and updated. Some of the staff had completed an infection control course and needed training food hygiene, diabetes and opportunities to undertake NVQ courses in care. Two staff had an NVQ in care. The home were not meeting the standard recommendation that 50 of the staff have achieved an NVQ in care by 31.12.05. The assistant service manger advised that she would be conducting supervision sessions with staff until the acting manager has completed training in supervising staff. This is essential for the staff during this period of change. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42,43 The home needs a qualified, registered manager. The guests’ best interests and safety are considered paramount. Staff would benefit from up to date training in safe working practices. Some aspects of health and safety need improving and a quality assurance system introduced. EVIDENCE: The home is without a registered manager and HFT are advertising for a manager. The senior support worker is temporarily working full time and acting up as manager, supported by the assistant service manager who is based at the home for three days during the week. The acting manager has an NVQ level 3 in care and has worked at the home for two years; hence knows the service. She has not undertaken management training and a supervisory course is a priority. At these visits she demonstrated her willingness and skills to managing this service on a temporary basis. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 22 The assistant service manager advised that she and the acting manager will be reviewing all the documentation and records in the home. The home has the majority of policies and procedures listed in NMS, Appendix 2. The service did not have a quality assurance system with annual development plan and annual audit of the service. A health and safety audit was said to have been carried out by HFT in May 2005 but the report could not be located. The team had been requested to visit again to carry out risk assessments of the premises. The assistant service manager had been completing monthly reports of her visits to the home and sending copies of the reports to CSCI since September 2005. The standard on safe working practices was assessed. It was apparent that there were systems in place to ensure the health and safety of the service users and staff. However aspects needed improving. Details of the training staff had received in safe working practices were not available, having been sent to HFT area office. The acting manager advised that some staff had completed a course in inflection control (previous requirement). Training for staff in food hygiene was still awaited (previous requirement). Policies and procedures for health and safety were in place. Risk assessments for the premises were due to be carried out by HFT. The home was keeping a record of accidents. The hot water outlets were being tested monthly and the findings recorded in detail (previous requirement). The hot water was below the recommended temperature if tested when the guests were staying. It is recommended that the hot water outlets be tested weekly. The portable appliances had been tested since the last inspection (previous requirement). A certificate of electrical safety was in the home (previous requirement). The recommendations from the legionella assessment were actioned, during the inspection, by the acting manager. The fire risk assessment was in the home and had been reviewed in October 2005 (previous requirement). Consideration should be given to having a more detailed assessment for the home, which includes the rooms. Records of checks on the fire precautions were being kept. It was recommended that the smoke detectors have a monthly visual check, which is recorded. Staff had received fire awareness training but it was unclear whether this had taken place quarterly, as required. A fire door to the office was hooked open and the acting manager immediately arranged for this hook to be removed and for the fire door to be kept shut (and locked when not in use to keep the guests’ records safe). Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 23 The service was discussed and the managers advised that a request to Social Services was made two years ago to review the funding arrangements because many of the guests staying have higher dependency needs. The home lends itself to accommodating service users with physical disabilities such as mobility problems. Guests with dual disabilities are being provided with a suitable service. 8 guests have been assessed as needing 1:1 support. However this means additional staff have to be on duty – 3 or 4 staff rather than 2 and HFT advised that they are funding this, which is not viable long term. Hence there need to be re-assessments of the guests using the service and of the fees paid, as a priority, for the service to be viable and secure for the service users. The service’s business and financial plan should be available for inspection and reviewed annually. The service had appropriate insurance cover. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 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 2 2 2 3 X 4 x 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 2 34 X 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 2 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 2 X X X 1 X X 2 2 Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4 Requirement The statement of purpose and must be reviewed and updated to include all the information outlined in Standard 1, Regulation 4 and Schedule 1. (timescale of 31.10.05 not met) The service user guide must be reviewed and updated to include all the information outlined in Standard 1, Regulation 4. (timescale of 31.10.05 not met) A contract/statement of terms and conditions, that includes all of the information detailed in Standard 5.2 and in a format appropriate to the service users’ needs, must be provided for all of the service users. The service users personal records must be kept securely in the home in a locked cabinet or locked room. (timescale of 31.10.05 not met) The staff must receive training from a health care professional regarding diabetes. The 6 requirements outlined in the pharmacist inspector’s letter of 17.08.05 must be implemented. DS0000018489.V277739.R01.S.doc Timescale for action 31/03/06 2 YA1 5 31/03/06 3 YA5 3 31/03/06 4 YA10 17 13/01/06 5 6 YA19 YA20 13,18 13 28/02/06 28/02/06 Foxlydiate Mews, 1 Version 5.1 Page 26 7 YA24 23 8 YA33 18 9 YA35 18,13 10 11 12 YA36 YA37 YA39 18 8 24 13 YA42 13,18 14 YA42 13 15 YA42 13,23 The heating and hot water system must be improved to ensure there is a continual supply of hot water in the home and the premises are maintained at a temperature of 21°C. (timescale of 30.09.05 not met) HFT must fill the vacancies so that the service has a permanent staff group. (timescale of 31.10.05 partially met) The home must have a training programme for 2006, which includes NVQ training. Individual training and development assessment profiles must be in place for each member of staff. Staff must have at least six supervision meetings a year, which are recorded. A suitably qualified and experienced manager must be appointed. A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and all of the aspects of Standard 39. All staff must have up to date training in safe working practices, particular food hygiene. (timescale of 30.09.05 partially met) Risk assessements must be carried out for all safe working practices and available in the home for inspection. The staff must receive training in fire awareness, quarterly. 28/02/06 28/02/06 31/03/06 28/02/06 28/02/06 31/03/06 31/03/06 31/03/06 28/02/06 Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 27 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 7 8 9 Refer to Standard YA1 YA6 YA14 YA19 YA20 YA32 YA42 YA42 YA43 Good Practice Recommendations The service user guide should be in suitable formats for the service users. A process to formally review the service user plans six monthly or as needs change, should be introduced. Consideration should be given to the home having a mini bus with wheelchair access. Respite service users would benefit from having health action plans. The 4 recommendations outlined in the pharmacist inspector’s letter of 17.08.05 should be implemented. 50 of the staff should have an NVQ in care. The hot water outlets shoud be checked weekly and recorded. The smoke detectors should have a monthly, visual check which is recorded. The home should have a business and financial plan which is reviewed annually and avaialble for inspection. Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Foxlydiate Mews, 1 DS0000018489.V277739.R01.S.doc Version 5.1 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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