Inspection on 27/02/06 for Gombards

This inspection was carried out on 27th February 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gombards 14/09/07

Gombards 30/01/07

Gombards 24/05/06

Gombards 04/05/05

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Gombards 6 London Road Welwyn Herts AL6 9EL Lead Inspector Mrs Jan Sheppard Unannounced Inspection 27th February 2006 11:00 Gombards DS0000063291.V283057.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 Gombards DS0000063291.V283057.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. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Gombards Address 6 London Road Welwyn Herts AL6 9EL 01438 712892 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) None United Response Sheena Jean Mackenzie Bagnall Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th May 2005 Brief Description of the Service: Gombards is a newly built home first registered in 2005. It was purpose designed with full wheelchair accessibility and was built as two self contained units each catering for four service users with learning and physical disabilities. The home which is jointly owned by Health, Social Services and by Aldwyck Housing Association is managed and run by United Response (a voluntary organisation). The residents and staff who had lived together for many years, moved from another home in St Albans where they were resettled following long-term institutional care. The home in St Albans did not meet the new environmental standards. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This service has been subject to a number of multi disciplinary meetings held under the joint working procedures for the Protection of Vulnerable Adults following information and concerns brought forward by a whistle blower. This is the second unannounced inspection of this inspection year. This report is based on an inspection visit made on 27th February 2006, between 10.50 and 16.15,which was carried out by three inspectors one of whom was in the home for the whole day and two who attended for part of the day, a total of 9.5 hours was spent on this inspection. Before the visit took place the records of CSCI contact with Gombards since the last inspection were re-read. These included records of cause for concern meetings, complaints and notifications of accidents, incidents and deaths. Since the last inspection, the manager the deputy manager and two senior support workers have been suspended from their duties pending disciplinary investigations. Another experienced registered and qualified manager from the same organisation (United Response), Ms. Terri Matthias, has been bought in to manage the home temporarily on a part time basis. She had been working in the home, as manager, for only four weeks prior to this inspection. The focus of this inspection was to follow through the standards of personal care being provided and to check the requirements from the last inspection. Two inspectors spent the morning talking with the staff, communicating with the residents (none of whom have any speech) and observing the interaction between residents and staff as they assisted the residents with activities and the preparation of their lunch. The third inspector spent the time until mid afternoon inspecting the building and checking care and administrative records with the manager and deputy manager before observing the residents who had been attending day care return to the home in mid afternoon. One of the requirements made during the last inspection has not been fully met. A further 11 new requirements and 3 recommendations have been made following this inspection. What the service does well: The service provides the residents with an attractive and homely environment where they receive continuity of care from staff who have known many of them since they were children, all residing together in a long stay hospital. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 6 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. Gombards DS0000063291.V283057.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 Gombards DS0000063291.V283057.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): 2 The home has policies and procedures to meet the requirements of this standard. EVIDENCE: At the last inspection this standard was met for the two new residents who were being introduced into the home. It was noted during this visit that both of those residents appeared well settled into the home. As no further new residents have been admitted to the home since then this section was not fully inspected. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 7 Each resident has a care plan, the format of which has recently been changed to provide a more easily accessible document which includes full details of how individual care needs should be met, risk assessments and the dates and minutes of care plan reviews. EVIDENCE: The format of the new care plans is clear and concise and for the plans examined where full details had been transposed from the old document this new format was seen to be advantageous. Information on the different aspects of care is filed in separate sections so that it could be easily located, and contributions from other professionals, for example notes from visiting Nurses and Consultants reports were found to be clearly identified. The manager explained that the residents key workers are compiling the new plans and she said that this exercise was currently being given priority in the home to ensure that all the residents plans were maintained to a similar standard. This process needs to continue to ensure that all the plans contain adequate detail as to the nature of the care needs and how these should best be met in accordance with the residents likes and wishes and with due attention to their health and safety. Staff must sign and date the care plan, as it is compiled/reviewed. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 10 Some staff are still recording information, which on a day-to-day basis is not relevant e.g. “bowels open”. Records should only be maintained where a need has been identified. Institutional type practices must cease. Service users must be allowed to take risks and retain as much independence as possible. One daily record entry noted that a service user refused to go to sleep so the senior member of night staff removed their toy dog that they were playing with. This is clearly unacceptable and is indicative of the attitude of a small minority of the staff. Photos were on display that were clearly inappropriate and did not respect or uphold service users dignity. The photos included a resident naked except for continence aids sitting on their bed. The manager addressed this immediately and staff were rearranging the photos during the inspection. A requirement has not been made as this has been seen as addressed. Although it is of concern that staff were not able to identify the pictures as a problem for themselves. The management are trying to address these issues and training has been arranged. Staff confirmed that as none of the residents has any speech, formal residents meetings are inappropriate but consultations with them concerning all aspects of their life and of living in the home is carried out mainly on an individual basis by their key workers who have a good understanding of their various ways of non verbal communication and can interpret what they may mean. Such consultations are carried out on a continuous and often informal basis whenever the opportunity arises. It is recommended that notes of these conversations are recorded in their care plans so as to fully evidence that adequate consultations are taking place and also to make this record available for all staff who may be caring for the resident. Where service users relatives or advocates have been consulted this too should be recorded. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Five of the residents have day centre activity programmes, which offer them the opportunity for personal development alongside peers of a similar age and ability. Similar programmes must be put in place for the other two residents. The home offers a leisure activity programme with outings into the local community. Service users rights must be protected and respected. There is a nutritious and varied menu. EVIDENCE: The five residents with day care activity programmes attend for either three or four days each week. The classes and activities they participate in are chosen to meet their interests and where possible to enable them to develop further their life skills. The manager said that the social workers for the residents currently without any such programme had been asked to assist with arranging one. Outings into the local community are arranged for the residents when, weather permitting, walks into the local village and bus rides into the countryside, to visit a local pub for lunch or perhaps to a garden centre are undertaken. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 12 It was seen that when such outings had occurred records of these were now made in the residents care plans or on their daily diary notes. On the day of this inspection a resident was walked by their careworker into the village to buy some ingredients for their evening meal. One of the issues raised about the service was that records of activities were being completed by some staff although the activity had not taken place. The management stated that a procedure for auditing activities had now been put into place. Visitors are always welcome in the home. Many of the residents have relatives who are able to visit regularly and several have over the past year been helpfully involved in establishing the new environment and generally assisting in establishing a homely feel to this new building. One service users had a baby listening alarm in their bedroom. The rationale for use of such equipment must be clearly recorded with agreement from the parties involved – including the placing social worker and family. The record must also indicate when this equipment is to be used. Meals were seen to be individually prepared for the residents at times to suit them and for lunch a variety was offered to meet their particular likes and wishes. The special dietary needs of one resident were seen to be set out in detail and staff confirmed that the visiting dietician assists them with these. The residents weights were seen to be regularly recorded. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,20 and 21. The home has well established links with local medical and nursing staff with whom they often work co-jointly. The administration of medication procedures and systems need addressing so that service users and staff are protected. Many of the care staff have worked with these residents for many years, some since childhood, and so have had time to develop an understanding of their care needs and individual likes and wishes. EVIDENCE: Staff were observed to be meeting the care needs of the residents in an individual and kindly manner. On two occasions the inspector witnessed the residents and staff having a laugh together in a relaxed manner and it was evident that there was good rapport between them. The home uses the MDS, monitored dosage medication system, supplied by a local chemist. The MAR, medication administration records, were seen to be well maintained and are subject to regular management checks. Some liquid medication was found to be being stored at the incorrect temperature. To fully meet the standard a number of requirements are made; a) the present location of the medication storage cupboards in the laundry room is unsatisfactory because of the excessive heat they must be moved to another Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 14 location where the temperature can be appropriately regulated. Medication stored outside of the manufacturers instructions may not be effective. b) the size of these cabinets are barely adequate for the contents in daily use and for the supplies that need to be maintained. Adequate sized cabinets that meet the requirements of the Royal Pharmaceutical Society are required. c) the home is required to have a policy concerning Homely Remedies. d) the home is required to have a Controlled drugs cupboard and register. e) photographs of the residents should be in place alongside the MAR record sheets. f) the home is required to have a small medication fridge. g) details of known allergies should be placed alongside each residents MAR record sheets. h) a list of signatures of the staff who administer medication must be kept for auditing purposes. i) clinical waste bins are required for the areas where medication is stored and administered. The care plans evidenced that for some residents consultations with relatives had taken place concerning their wishes about end of life and funeral arrangements for the resident. The homes records evidenced that the home had fully involved the relatives in the final illness and very recent passing away of a resident who returned home from hospital, as was her families wish, to spend her final days at Gombards. Counselling will be made available to any residents or staff as required. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 A complaints procedure is in place. Policies and procedures are in place for the protection of the service users. EVIDENCE: Since the last inspection the home has not directly received any formal complaints. However a whistle blower has drawn attention to a number of deficiencies and problems in the home and these are still being investigated by the Company, United Response, and via the joint agency strategy meetings held under the arrangements concerning Adult Protection led by the local authority. A high level of ongoing monitoring by Hertfordshire’s Adult Care Services has been in place since the issues were first raised. It is of a great concern that the whistle blower had first raised the issues with United Response but action was only taken belatedly, Hertfordshire Adult Care Services and CSCI were not kept informed. The whistle blowing policy available on the day of the inspection was of a poor print quality making it difficult to read. Two whistleblowers have come forward to the Commission who both state that their concerns were first raised with the provider. Both allege that action was not forthcoming and their rights as whistleblowers not upheld. The provider is reminded that it has a duty to protect whistleblowers. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 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 the following standard(s): 24,25,26,27,28,29 and 30. Gombards is a recently built purpose designed building which provides a homely and very well appointed environment for its residents whose physical needs are specifically catered for; the building is fully wheelchair accessible and has specialist overhead tracking in bedrooms and in the specially adapted bath and shower rooms. Overall the building provides a safe environment although requirements are made about some areas of deficiency and lack of routine maintenance, which could compromise the safety of the residents. EVIDENCE: On the day of this inspection the home was found to be clean and hygienic. Each resident has a single spacious bedroom supplied with specialist furnishings and equipment (e.g. walking aids, adapted wheelchairs, special beds and over head tracking) that have been provided to meet their particular needs following an Occupational Therapy assessment. The manager explained that recently the staff have been assisting the residents and in some cases assisted also by their families, to restyle the furnishings and decorations in the bedrooms so as to make them more age appropriate for the residents and to better reflect their tastes and interests. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 17 Several items of new furniture including specialist beds have been purchased so that the needs of the residents can be fully met. The bedrooms were attractive and homely although they all lacked adequate storage space and some walls lacked pictures or other ornamentation. Whilst new pictures etc., were being chosen specially designed chairs are provided in the lounges (these again to meet the specific needs of each resident) and t.v, music and special lighting systems are provided. The sensory equipment stored in the ‘sleep in’ room must be made available so it can be enjoyed freely by service users. Each unit has its own fully equipped laundry, which very adequately meets the needs of the residents. However both laundries suffer from a lack of storage shelving and it could not be evidenced that red alginate bags are being used to launder soiled linen. Requirements are made so that infection control can be assured. The garden appeared to be in need of some maintenance and the manager could not evidence that any routine maintenance programme had been established for this area since the home opened. A requirement is made. A number of safety issues require attention so that the safety of the residents is not compromised and is maintained at all times. It is required that; a) safety catches on windows must not be overridden b) COSHH cupboard doors must be kept locked at all times. c) a safety grill is fitted at the top of the stairs. d) liquid soap, towel and toilet roll dispensers are needed in all the bathrooms and toilets. e) all bedrooms are required to have a lockable space. f) bedroom doors are required to have safety locks. g) the exterior of the home including the gardens are subject to a routine maintenance programme. h) the problems with the assisted bath panels is addressed and additional panels are not stored in the home. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 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 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): 32,34,35 & 36 The number and mix of staff on duty during the day is sufficient to provide support for the residents at an unhurried pace. The staff numbers at night are not adequate to safely meet all the residents needs. The home is staffed by experienced carers but 50 of staff do not hold the required NVQ qualification at level 2. Regular staff supervision is arranged for all staff. Although the home has the required recruitment policies and procedures to ensure the protection of the residents but it could not be evidenced that these had always been followed. EVIDENCE: Staff were familiar with the needs of the residents and there appeared to be a relaxed atmosphere between the staff and residents this being particularly noticeable when the residents were welcomed back into the home in mid afternoon when they returned from their day care activities. The number of staff seen to be on duty during the day of this inspection appeared to be adequate to meet the residents needs. However, the night rotas showed that two staff only were employed for night duties (one awake and the other asleep). Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 19 As the majority of the residents now require individual care delivered by two careworkers and considering the layout of the building (two separate units over two floors), these numbers are not considered adequate to safely meet the residents night care needs and to provide cover for any emergency situation that may arise. It is a requirement that night staffing levels are increased to meet service users needs. It is suggested that this would be two waking and one sleeping in night careworker. The records showed that training courses are planned throughout the year although it was not always possible to evidence which courses had actually been attended. Standard 35 is not met, as it could not be evidenced that 50 of carers held an NVQ qualification at level 2. Some training issues have been identified in relation to care provision. This is being addressed by the provider. The records evidenced that monthly staff supervision meetings for all staff had been established by the new manager since the beginning of the year. It is a requirement that the Staff Policy Document Book which has to be available for all staff to read at any time is replaced with a copy where the printing can be easily read and that amendments are made so that the correct name and address of the CSCI is shown as it currently refers to NCSC. The records dealing with the employment of one new staff member appointed during 2005, and since the last inspection, did not evidence that CRB checks or references had been taken up. The new manager agreed to investigate this immediately. A requirement is made. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 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 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 and 42. The new management structure in the home has begun to introduce practice changes that are being made to ensure that the residents are safe, well cared for and benefit from a well run home. Although some lapses in health and safety issues were noted, see comments for standard 24, staff appeared to have an overall awareness of health and safety issues for the residents protection. EVIDENCE: The homes records evidenced that the overall management of systems within the home had improved since the arrival of the new manager some four weeks previous to this inspection. A number of changes in procedures and working practices had been introduced and others that were being considered were discussed with the inspectors. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 21 Regular visits are being made to the home by representatives of the company, United Response, which includes consultation with the residents and consultation and feedback to their relatives. It is a requirement that the management continues to introduce and review the new better practices that are being introduced into the home. One of the issues raised by the whistle blower included that the home was not run in the best interests of the residents but for the benefit of the staff. A number of institutional type practices were disclosed. These practices were possibly common practice may be 15 years ago but care provision has moved on. Staff must be made aware of modern practices. This is also apparent in some of the current recording practices. Some staff still insist on recording inappropriate information such as “bowels open” rather than only making a record if the need as been identified. The management have introduced new care plans and daily records to try to overcome these issues but a core of staff appear to be undermining the new systems. Daily records are not routinely signed by the person making the entry. The manager stated that training is to be provided to address these issues. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 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 Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x x x LIFESTYLES Standard No Score 11 x 12 2 13 3 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 x 2 3 2 x x x x 2 x Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 23 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 YA12 Regulation 16(2)(n) Requirement It is a requirement that Day Care programmes are established for the two residents who currently have no day activities All entries made into the residents care plans must be signed and dated. Regular attention must be given to the maintenance of the garden. Adequate storage shelves must be provided in the laundry and red bags must be used for all foul linen. To ensure the protection of the residents full CRB checks and two references must be taken up for all new staff before appointments are confirmed. This requirement remains outstanding from the last report. The staff policy manual must be replaced with a more legible version and the information concerning the CSCI corrected Waking night staff numbers must be increased to meet service users needs. DS0000063291.V283057.R01.S.doc Timescale for action 30/04/06 2. 3. 4. YA6 YA24 YA24 17 23(2)(o) 23(2)(l)& 13(3) 19 31/03/06 30/04/06 30/04/06 5. YA34 31/03/06 6. YA35 17 31/03/06 7. YA35 18(1)(a) 30/04/06 Gombards Version 5.1 Page 24 8. YA24 13(4)(c) 9. YA20 10. YA35YA32 11. YA37 12. YA7 A number of omissions to the arrangements to ensure the Health and Safety of the residents are required see text for this standard for the detail of this requirement. 13(2) A number of amendments and additions are required to the medication storage and administration arrangements See the text for this standard for the detail of the nine changes required. 18(c)(i)&(ii) Appropriately trained and competent staff must be employed within the home. All staff must be trained in providing a person centred service to the residents in Gombards that meets their needs. 24(l)(a)&(b) It is a requirement that the management continues to introduce and review the new work practices in the home. 17 Records must be kept in the care plans of the content of the consultations with service users. This is to evidence that adequate consultations with them are taking place regularly. 30/04/06 30/04/06 30/04/06 30/04/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA24 YA7 Good Practice Recommendations It is recommended that the Sensory Room is arranged so that residents can benefit from the use of this facility. It is recommended that notes of the key-workers consultations with the residents are made in their care plans to act as a formal record of the facts and to evidence DS0000063291.V283057.R01.S.doc Version 5.1 Page 25 Gombards 3 YA35YA32 regular consultations with them. 50 of staff should be trained to NVQ level 2. Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Gombards DS0000063291.V283057.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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