Inspection on 10/06/05 for Gatehouse Cottages Care Home

This inspection was carried out on 10th June 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Gatehouse Cottages Care Home 28/01/10

Gatehouse Cottages Care Home 29/09/09

Gatehouse Cottages Care Home 18/01/08

Gatehouse Cottages Care Home 18/01/07

Gatehouse Cottages Care Home 27/06/06

Gatehouse Cottages Care Home 01/12/05

Gatehouse Cottages Care Home 20/12/04

Gatehouse Cottages Care Home 29/04/04

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

CARE HOME ADULTS 18-65 Gatehouse Cottages Stallingborough Road Immingham Grimsby North East Lincs DN41 8BP Lead Inspector Matun Wawryk Unannounced 10 June 2005 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. Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Gatehouse Cottages Address Stallingborough Road, Immingham, Grimsby, North East Lincs, DN41 8BP 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) 01469 574010 Health & Care Services (UK) Ltd Barbara Anne Hancock Care Home 27 Category(ies) of LD Learning Disability(27) registration, with number PD Physical Disability (20) of places Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20.12.04 Brief Description of the Service: Gatehouse Cottages is a care home providing personal care with nursing and accommodation for up to 27 adults aged 18-65 with moderate and severe learning disabilities, 20 of these places are for service users with physical disabilities.Gatehouse Cottages is owned by Health and Care Services (UK) Limited/Craegmoor healthcare. The home is situated in the countryside a few miles outside Immingham in a fairly isolated position; there is only one neighbouring property. There is a regular bus service and the home has its own transport. An enclosed garden is to the rear of the building and parking space is provided at the front of the home.The accommodation comprises of 3 separate units; there is a purpose built ground floor main facility, the first floor of this is the Studio and there is a separate 3-bedroom house nearby which is the Lodge. There are two shared bedrooms in the main facility and one in the Studio the rest being single. None of the bedrooms have en-suite facilities. A range of aids, adaptations and equipment are provided in the main facility including an Aqua Nova bath, a Jacuzzi and a sensory room. Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on the 10th June 2005 and lasted for nine and a half hours. To find out how the home was run and if the clients who lived there were happy with the care they received, the inspector spoke to the manager, one nurse, three support workers and the activity co-ordinator who were working in the home at the time of the inspection. The inspector also spoke to the parents of one client. The majority of clients who live in the home did not have good verbal communication skills. Therefore the inspector spent time in the dining room at lunchtime observing how staff helped the clients with their meal and spoke to a small group of clients who were in the studio flat. A tour of the home was carried out and paperwork kept in the home was looked at to make sure staff were trained to do their job safely. Paperwork was also looked at to make sure that the home and the things used in the home were safe. The manager of the home Barbara Grey had been in charge since December 2004 and had tried to make sure some of the things that needed to be done since the last inspection had been carried out. What the service does well: What has improved since the last inspection? The sitting room and one of the bathrooms had been redecorated. Discussion with staff and examination of records showed staff had had an annual appraisal. This is a positive development and represents a significant improvement since the last inspection Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 6 The home had a good mandatory training programme. Most of the staff working in the home had been provided with training on how to lift people properly, fire safety and first aid. 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. Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 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 Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 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) None of these standards were assessed on this occasion because no changes had been made to the statement of purpose and service user guide. There had been no new admissions to the home since the previous inspection therefore it was not possible to explore whether the information provided prior to admission was sufficient. EVIDENCE: Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 9 Staff spoken to were knowledgeable about the care needs of the clients. Care plans and risk assessments had not been adequately monitored and/or evaluated. Without this there is no assurance that the care needs of clients will be met. EVIDENCE: Case tracking of four clients was completed. This included, examination of care records and discussion with six members of staff and the relatives of one client. Care plans had not been reviewed in line with guidance set out in NMS 7. There were risk assessment tools for mobility, falls and nutrition. Daily records were maintained by the nurses and described care provided and communication with other parties for example occupational therapists and G.Ps. Individual service user plans are available however they did not reflect the full range of needs of clients and there was some duplication of information. Risk assessments and care plans had not been revised to reflect the changing needs of clients for example one clients records showed this individual was Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 10 exhibiting challenging behaviour on a regular basis and on two occasions staff had used physical intervention. The clients risk assessment had not been revised to reflect a need for this and a behaviour plan, which describes in detail how staff should manage this client’s behaviour, had not been developed. Although incidents of challenging behaviour were being recorded there was no evidence that these incidents were being monitored and evaluated on a regular basis to ensure lessons can be leant. Two service users had been prescribed medication for behaviour management, to be given as and when needed. The registered person must ensure where as and when needed (PRN) medication is prescribed as a behaviour management treatment a medication care plan is developed setting out the circumstances when the medication should be administered. Alternatively this should be set out in the behaviour management plan to support a consistent approach to medication administration. The administration of such medication needs to be regularly monitored to establish patterns or trends. Care plans were produced in standard written format, this does not assure the accessibility of these for the clients. The need to produce care plans in a more accessible format remains an outstanding requirement from previous inspections. Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 15, 16 & 17 The recreational and social needs of clients are well catered for. Daily routines observed in the home are flexible and promote choice for the clients as far as practicable. The meals in the home are good offering both choice and variety. EVIDENCE: Evidence from talking to six staff members and examination of four clients care records showed staff placed emphasis on meeting the social and recreational needs of clients. The home employs an activity co-ordinator who takes responsibility for organising a weekly programme of activities on an individual and group basis. Records of activities were maintained. The activity coordinator had not had any specific training in planning and running activities for people with complex needs. This needs to be an area of future development to enable her to develop new ideas for activities in the home All the staff spoken to said clients were able to exercise choice in aspects of their life and daily routines as far as they were able to. Family and friends Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 12 were welcome at anytime. The parents of one client who the inspector spoke with confirmed this. All six members of staff spoken to spoke positively about the meals provided and described the quality, choice and variety of the meals as good. Three clients the inspector spoke to confirmed this. A number of the clients require assistance to eat. The inspector observed the lunchtime meal and staff were observed to assist clients in a sensitive manner. Examination of the homes menu showed a variety of food was available to the clients. Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 7 19 Personal support is offered in such a way as to promote and protect the client’s privacy and dignity. The health needs of clients were reasonable well met with evidence of attempts to ensure regular health checks are arranged. The manager confirmed one requirement made in the last inspection report concerning annual health checks had only been partially met. EVIDENCE: Four clients care files were examined as part of the inspection process. The inspector also spoke to six staff members and the parents of one service user. The majority of bedrooms are for single occupation. Privacy screens are provided in shared bedrooms. Care plans detailed how personal care should be provided. There were minimal records to support that clients had had an annual health check. This remains an outstanding requirement from the previous inspection. Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 14 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) 22 & 23 Staff were aware of the complaints procedure and could identify whom they would speak to in the event of a complaint. Arrangements for reporting and protecting clients need to be more robust. Staff were knowledgeable about protecting clients from abuse but information regarding the correct procedures for referral and investigation of abuse must be made available. Some staff had been provided with physical intervention training. Risk assessments and care plans must be in place, which supports staff practice in this area. EVIDENCE: A copy of the complaints procedure was available in the home. Staff and the one relative spoken to reported understanding of the complaints procedure and commented that they knew whom to contact to make a complaint. The manager reported that she had completed a draft procedure for responding to allegations of abuse but was not able to provide the inspector with a copy of this at the inspection because of problems with the homes printer. The manager was advised to forward a copy onto the Commission for Social Care Inspection, which she agreed to do. Examination of training records showed some staff had had adult abuse training; further training was planned for June 2005. All staff spoken to reported they would feel confident about reporting bad practice and were able to describe the action they would take in the event of suspicion of abuse. Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 15 Examination of records showed incidents of challenging behaviour and use of physical intervention was being recorded. However there was no evidence of a structured and formal approach to the monitoring and evaluation of incidents occurring in the home. Records for one client showed the individual exhibited challenging behaviour frequently and on two occasions physical intervention had had to be used. An intervention plan completed in 2001 noted restraint should be used as a last resort. However a current risk assessment, which clearly identified the need for use of physical intervention and a management plan, which supports the risk assessment had not been completed. Similarly the risk assessment for another client did not set out in detail how this individuals challenging behaviour should be managed. The manager was advised to complete a revised risk assessment and management plan for both of these individuals as a matter of priority. The inspector will carryout a check to ensure this has happened. At the last inspection a requirement had been made requiring the trainer who facilitates the Crisis Intervention Training to provide evidence of competence to provide this training was met. However the certificate provided states it was only valid until 13th November 2004, after which it is renewable on satisfactory completion of an update course. The registered person must confirm to the CSCI that this individual has completed necessary refresher training and is certified to carryon providing training in this area. Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 16 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, 27 & 30 The sitting room had recently been redecorated and a bathroom had been refurbished, however other communal areas of the home do not provide clients with pleasing and comfortable surroundings. EVIDENCE: There were no private areas for visitors and the one relative the inspector spoke with commented upon this. The home employs a cleaner for four hours per day over five days. This means that for two days a week there is no cleaner. The inspector noted that some areas of the home appeared untidy, windows needed cleaning, doors and paintwork was marked and stained. The home is large and the substantial care needs of the clients puts additional pressures on the cleaner. The inspector recommends a review of the domestic cleaning hours to ensure adequate time is available to ensure the home provides a clean and safe environment for clients. Wallpaper in a number of rooms was torn and woodwork and kick boards were badly chipped. This creates a poor first impression of the home. Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 17 Cupboards in the studio kitchen were broken and staff reported that they were short of basis kitchen equipment for example chopping boards. A tour of the home showed a number of other areas required attention, in particular: • carpets including the hallway and several bedrooms were stained and dirty and needed cleaning or replacing. Although this does not pose a risk to clients it does not create a pleasing and pleasant environment The dinning room and hallway in the main home needs redecoration. The hallway in the Lodge had bare plaster showing. There was bare plasterwork above the boiler in the kitchen. Again whilst this does not pose a risk to clients it does not create a pleasing and pleasant environment The main kitchen window does not open which restricts ventilation to this area. The window requires repair or replacement. The fly screen was broken and therefore requires repair or replacement. 6 water outlets were checked, temperatures were very low, ranging from 17 to 30 centigrade. This means clients are potentially washing in luke warm water The radiators in the Lodge to not have thermostats or covers fitted. This poses a potential health and safety risk to the clients living there. The external door adjacent to the side car park was damaged. This poses a potential security problem. The door must be repaired or replaced. Staff commented on the lack of adequate external lighting around the home. Again this poses a potential safety issue. The toilet seat was missing from the toilet in the lodge and the hot water tap did not work. This poses a health and safety risk to clients living there. The Jacuzzi was broken and therefore requires repair. Whilst this does not pose a health and safety risk to clients it prevents clients from accessing an enjoyable and therapeutic activity. • • • • • • • Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 18 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 and 36 Observation of staff showed they appeared to be interested in the clients and were observed to speak to the clients in a kindly manner. There was evidence staff had been provided with mandatory training More specialist and service user specific training is needed. The home maintains staffing levels as required by the existing staffing notice. The Manager had completed an annual appraisal for staff. Limited progress had been achieved in proving staff with formal recorded supervision. Further progress in this area is needed EVIDENCE: The inspector examined policy guidance; a sample of staff training records and spoke to six members of staff and the parents of one client. The inspector also observed staff carrying out their work. Staff were observed to interact with the clients in a respectful manner. One client’s relatives who spoke to the inspector confirmed staff respected their son’s dignity and privacy. Training information and discussions with staff showed little formal training in learning disabilities and in the specific conditions of the current residents had Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 19 been provided. This needs to be an area of improvement to ensure staff have the necessary competencies to meet the needs of the clients. The home continues to provide staffing levels as required by the staffing notice as 31st March 2002. Examination of a sample of rotas showed the home had not fallen below this number. Agency staff were used periodically to ensure minimum staffing levels were maintained. Records showed on one occasion the home had failed to ensure a qualified nurse was on duty. Arrangements had been put into place to ensure this did not happen again. Discussion with staff and examination of records showed staff had had an annual appraisal. Staff discussions and records examined showed only a small number of staff had had formal recorded supervision. This must be an area of future development. Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 20 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 & 39 An experienced manager runs the home although the registration process is still to be completed. The home did not have a structured quality assurance programme based on a systematic cycle of planning, action and review which reflected the aims and outcomes for service users. EVIDENCE: The current manager was appointed to the home in December 2004 and there was evidence to show she was beginning to develop systems, which support effective leadership of staff and operations to ensure the health, welfare and safety of clients. The manager has not yet made an application for registration with the Commission. This must now happen. The manager is a registered nurse and has considerable care experience but has not yet completed the registered manager award. This needs to happen so that the manager can develop necessary management knowledge and skills. Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 21 Since the last inspection the manager had carried out a survey of relatives and professional staff for example G.P’s and Social Services workers to try and find out what they thought about the home. The results of these surveys were not available on the day of the inspection. An annual audit had not been completed. The registered person needs to develop consistent methods for checking the quality of the services provided by the home in line with National Minimum Standard 39. There were some deficiencies in ensuring the environment was safe for the clients, which need to be addressed. These matters are set out in other sections of this report. Please refer to pages 14 & 15. Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 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 x x x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 2 x x 2 Standard No 11 12 13 14 15 16 17 x x 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 3 x x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gatehouse Cottages Score 3 2 x x Standard No 37 38 39 40 41 42 43 Score 2 x 1 x x x x J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 23 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 2&6 Regulation 14(1)(b)S chedule 3(1) (a) Requirement Timescale for action 31.9.05 2. 6 15(2) 3. 7 13(7) The registered person must obtain a copy of the single care management assessment, or summary of this and a copy of the single care plan for all service users admitted through care management. (The timescale of 31/8/04 was not met) 31.7.05 The registered person must ensure that all service users and their representatives are involved in the development of their individual plan and that the plan is available in an accessible format or explained to them. The individual plan of care must be reviewed with the service user (involving family, friends, advocate and significant professionals as agreed by the service user) at least 6-monthly. (The timescale of 30/9/04 was not met) The registered person must 14.7.05 ensure that the use of particular physical interventions with particular service users is agreed in a meeting that includes a representative from the placing authority, relevant family Version 1.30 Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Page 24 4. 8 12 5. 9 13(4) 6. 10 12(4) (5) 7. 19 13(1) 8. 24 23 9. 23 13 (7) (8) members and an independent advocate. The policies and procedures must be amended and must reflect current legislation and case law as well as government guidance and professional codes of practice. It must describe the specific restraint techniques that could be used if necessary.(The timescale of 31/1/05 was not met) The registered person must ensure that service users have opportunities to participate in activities that will enable them to influence decision-making in home and contribute to the development and review of policies and procedures. The registered person must ensure that risk assessments for service users are agreed to by the service users or their representative and updated regularly.(The timescale of 31/3/05 was not met) The registered person must provide a policy and procedure on confidentiality and a statement setting out the principles governing the sharing of information with partner agencies. The registered person must ensure that all service users are given an annual health check; this must include a medication review. Arrangements must be in place by 30.9.05. The registered person must produce a planned maintenance and renewal programme for the fabric and decoration of the premises with timescales for action..(The timescale of 31/3/05 was not met) The Registered person must 31.6.05 31.8.05 31.6.05 Annually/3 0.9.05 31.8.05 30.6.05 Page 25 Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 10. 39 24 11. 39 12(1)(a), 24(1)(a)( b)(3) 12. 6,7, 23, 42 13(6) 13. 23 13 & 18 develop and make available an internal abuse procedure. The procedure must reflect the multi agency procedures in respect of referral and investigation. Guidance must set out in detail actions to be taken by staff in the event of an allegation including who should be contacted. Moreover guidance should cover actions to be taken in the event of an incident occurring out of mainstream office hours.(The timescale of 31/8/04 was not met) The registered person must develop a formal quality assurance and quality monitoring system, based on seeking the views of service users, family, friends and advocates in order to measure the success of meeting the aims of the home and leading to an annual development plan for the home. The registered person must ensure that views of stakeholders in the community (e.g. GPs; chiropodists; voluntary organisations) are sought on how the home is achieving goals for service users. (The timescale of 31/7/04 was not met, a new timescale has been agreed) The registered person must devise and implement a system in the establishment whereby the recorded episodes of restraint and challenging behaviour are reviewqed in a way that supports a review of each episode with a view to informing best practice in such circumstances. The registered person must carryout a check and then confirm to the CSCI that the 30.6.05 30.6.05 31.7.05 31.7.05 Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 26 14. 24 23 15. 16. 24 24 23 23 17. 18. 24, 30 42 23 13 19. 20. 24. 42 24, 42 13 23 21. 27 13 22. 23. 24. 25. 33 33 37 30 12,13,17 and 18 18(1a) 18 23 26. 36 18(2) person completing the CPI training has undertaken necessary refresher training The registered person must have the damaged cuboards in the studio kichen repaired. An audit of small kitchen equipment must carried out. Necessary equipment must be provided The registered person must have the hallway and dining room redecorated The registered person must carryout necessary redecoration of the hallway and the area near the boiler in the lodge The registered person must have the kitchen window repaired THe registered person must ensure water temperatures are maintained as near to 43 C as possible. THe registered person must fit thermostats or covers to the radiators in the lodge. The registered person must have the main door adjacent to the side car park repaired or replaced The registered person. must provide a replacement toilet seat in the bathroom in the lodge and ensure hot water is supplied. The registered person must ensure staff are provided with specfic service user training. The registered person must ensure 50 of care staff achieve an NVQ The manager for the home must achieve an NVQ level 4 or other recognised qualification The registered person must carryout an audit of all bedroom carpets, stained carpets must be cleaned or replaced The registered person must ensure staff are provided with 31.9.05 31.9.05 31.9.05 31.9.05 30.7.05 31.7.05 31.8.05 31.7.05 31.10.05 31.12.05 31.12.05 31.7.05 31.8.05 Page 27 Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 formal recorded supervision as a minimum of six times a year RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 30 30 42 42 Good Practice Recommendations The registered person should carryout a review of the domestic cleaning hours allocated to the home. The registered person should have the fly screen in the main kitchen repaired or replaced The registered person should carryout a review of the external lighting for the home to ensure adequet lighting is provided The registered person should have the Jaccuzi repaired Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Unit 3, Hesslewood Country Office Park Ferriby Road Hessle East Yorkshire HU13 0QF 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 Gatehouse Cottages J54_s2786_Gatehouse_v226904_100605_Stage 4.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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