Inspection on 16/12/08 for Hartfield House

This inspection was carried out on 16th December 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hartfield House 24/06/08

Hartfield House 03/03/08

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

CARE HOME ADULTS 18-65 Hartfield House 170 Roehampton Lane London SW15 4EU Lead Inspector Davina McLaverty Key Unannounced Inspection 16th December 2008 09:50a Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hartfield House Address 170 Roehampton Lane London SW15 4EU 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) 020 8780 0057 m.saddler@southsidepartnership.org.uk www.southsidepartnership.org.uk Southside Partnership Manager post vacant Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 18 24th June 2008 Date of last inspection Brief Description of the Service: Hartfield House is a care home providing respite/ rota and emergency care for up to eighteen service users with a learning disability, five of whom may also have a physical disability. Accommodation is provided in single bedrooms, double bedrooms and two semi-independent flat-lets. Since September 2007, the service has been owned and managed by Southside Partnership, having been previously run by Wandsworth Council. Hartfield House is located close to shops, pubs and other amenities. It has good access to public transport. A limited number of parking spaces are available outside the home. At the time of this inspection the weekly charge for respite/ rota care and emergency care is £1086.63 per week. Additional charges are made for some outings. Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection took place over one day and included a visit to the service by two Regulation Inspectors. When we visited we spoke to the people who work at the home and the manager. We also looked at records, observed what was going on and looked at the environment. Surveys were received back from three people who use the service, one staff member and one health/ social care professional. 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. The summary of this inspection report can be made available in other formats on request. Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 6 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 Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. There is up-to-date information about what people can expect from the service. Service users are appropriately assessed to ensure the service can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is an up-to-date Service Users Guide at Hartfield House that incorporates the Statement of Purpose. This provides written information regarding the service provided, what people can expect during their stay, their rights and who they can contact if they are not happy about something. There are also pictures throughout the guide to make the information more accessible to people who use the service. Most of the people who stay at Hartfield House for respite have done so over a number of years, staying for periods of one to seven days on a rota basis, throughout the year. The service has been working with care management teams to ensure that assessments are carried out on all people who use the service. This has involved recent assessments by the care managers and this used to update the Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 8 assessment information held by the home. The manager provided a plan of reviews that are due to take place for some of the service users. The new assessments provide much more up-to-date and relevant information about what the person likes to do and their needs around communication, diet, personal care and behaviour. There is also more information about the person’s family relationships and social needs. It is evident that work is still in progress in this area, and the manager said he has been working with care managers to ensure each person’s care is reviewed and up-to-date. The processes currently taking place must be kept ‘live’, and, due to the respite nature of the service, there must be regular reviews and reassessment of each person’s use of the service, and written documentation available to evidence this. Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. Positive improvements have been made to care planning, risk assessment and risk management to ensure a more user-focussed service. Further work is needed to ensure that people using the service are involved in their care planning, and that all relevant information is recorded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Improvements are being made to the care planning at the service, with most people who use the service now having an up-to-date support plan that is developed from the recent re-assessment of their needs. The staff feedback that they feel the support plans provide up-to-date and relevant information about people who stay at the home. There is a new support plan format that is being used to record relevant support information relating to the current individual needs of each person. Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 10 This includes information about areas such as support needed with personal care, cultural needs, activities, and the persons’ likes and dislikes. The recording of information in the support plans vary from being detailed to that of very little information given, or blank spaces where information should be recorded, eg. no information given under the heading ‘reason for referral’. The manager spoke about efforts made to introduce a more person-centred approach at the service, and that staff were having training in this. Evidence of this was seen in some of the support plans, with information about how people like to spend their time and what foods they prefer. However, in some cases attempts to record in a person centred way can be misleading. An example of this is where one support plan around communication needs states ‘…(resident) says he has limited vocabulary and will only answer yes or no when spoken…’, another example is where a support plan says ‘…encourage to make choice from clothes available…’. Similarly, there was little evidence that the people using the service are involved in developing their support plans. Some of the support plans also do not contain a photograph of the person using the service. A new format for recording risk assessments and risk management plans is now in use. These are in a good format, providing relevant information about risk issues, the evidence used for the risk assessment and trigger factors. A risk management plan is in place for each trigger, along with a crisis action plan, that details the actions that the person using the service and staff need to take to manage any risks. A good example of this is where the risk for one service user is their ‘wandering off’ when out with staff. The actions to manage this involve the service user staying with the group, and staff being aware of their habits/ behaviour, and reinforcing the risks to the person if they wander off from them when outside. The risk assessments are individualised to each person’s needs, where some are predominantly around physical and medical needs, with others around fire safety and social needs. It was observed that input from relevant professionals had been used to develop the risk assessments and management plans, with guidance from eg. physiotherapist, being incorporated into care plans around epilepsy needs. It is recommended that archiving of some of the information in the care files takes place, as in some files the information is repetitive and confusing as to what is most current. Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. People who use the service are supported to pursue activities and maintain community links. Improvements need to be made to ensure that people who use the service eat suitable food and that this is nutritious and fresh. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who stay at Hartfield House usually arrive on a Monday from their day centre, where they are shown to their room before joining the other people for the evening meal. The following Tuesday evening the people using the service attend a house meeting to discuss any group activities planned for the week, activities and menu suggestions. Minutes of these meetings are held. Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 12 Most people who use the service attend day centres or college during the week, although some spend the day at the service, having one-to-one input from staff. In the evenings and at weekends people who use the service can access the facilities in the games room, which is currently being refurbished. There are now more activities for people to do in this room, such as table ‘air hockey’ and a pool table for use. Staff say that they also sometimes take the people staying at the service out to the pub or bowling. Three people who use the service responded to our survey. Of these, one of them said that they are not able to make decisions about what they do each day, but that they can in the evenings. The service should make sure that the people using the service spend their time as they wish, and offer them appropriate opportunities during the day if they choose not to attend the day centre. The people using the service choose the meals for the week at the residents meeting on a Tuesday evening. A board on display in the dining area gives a photograph of what the evening meal will be, however the current meal displayed did not correspond with what was being planned for the evening meal. There is a good stock of food in the fridges, freezers and cupboards in the kitchen, to ensure that a variety of foods can be provided. The chef said that he orders the food. The care plans looked at indicate that one person currently using the service eats only Halal meat, due to religious reasons. The staff said that all meals are cooked using Halal meat. The freezers were seen to contain a lot of Halal meat. Of the care plans looked at, there was no record that other people eat Halal meat and it is unclear as to why only Halal meat is provided, where only one person using the service (at the time) eats this. This practice does also not take into account other people’s needs, or their desire to eat, or not eat, Halal meat, and it is unclear if they have been given an informed choice about this. This was highlighted to the manager during the inspection, and a requirement has been made for the service to address this. The previous key inspection of the service found that food jars are not being appropriately labelled when opened. This was found to still be the case, where the fridge contained a number of jars and packets of food that had been opened but not labelled as to when they were opened. The chef said that he uses the guidance on the jar label, such as he will dispose of the product if the label says this needs to be done after, eg being opened for three days. However, he was not able to show any evidence that he had recorded when the jars had been opened. A requirement has been made to address this. Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. Good improvements have been made to the reviewing of peoples support at the service and to the medication systems. Further improvements are needed to ensure that medication is managed robustly and to minimise risks to people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Feedback received from one healthcare professional that is involved with the service is positive, where they said that staff at the service appropriately seek their advice, and that they feel there is good communication. They also say that they feel that the staff are respectful of peoples’ privacy. The care files contain copies of correspondence from professionals regarding the health and social care needs of the people who use the service. Reviews of each persons care needs are taking place at the service, and the manager showed evidence of dates that had been arranged for those still to take place. As stated earlier in the report, the service must make sure that reviews are ongoing to ensure that the service is the right place for the people using this. Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 14 Good improvements have been made to the medication systems at the service, and this is monitored through medication audits carried out by two staff at the beginning of the day and night shift each day. This identifies problem areas such as unclear labelling of medication. All the medication currently held at the service was checked during the inspection. This were all seen to be in good order, with one exception being where staff had crossed out a dosage of medication on the medication administration record (MAR), and replaced it with a higher dose, without initialling, dating and providing an explanation for this. It was also found that the ‘allergies’ section was not completed on each MAR chart. There are two other medication cupboards that hold all the medication, plus a controlled drugs cupboard. There is a fridge that was seen to contain a tube of Timodin cream for one person. The fridge is currently not lockable, yet needs to be kept locked at all times. Staff have received recent training in medication administration, and the manager must ensure that there is continual monitoring of their competency in handling medication, through audits and supervision. The service has recently implemented new policies, which cover all relevant areas such as medication storage, receiving medication into the service and controlled drugs. Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. There are appropriate procedures for addressing complaints and ensuring that risks to people using the service are minimised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Feedback from residents is that most know how to raise concerns or make a complaint, however some do not, and the service should ensure that they are aware of how to do this. The service has an appropriate complaints procedure that provides timescales in which any complaint will be acknowledged and investigated. This is also available in a more accessible format, with pictures, for the use of the people who use the service. The service keeps a log of any complaints received, including the outcome of the complaint. However, a record should also be maintained of whether the complaint has been upheld or not. There are policies and procedures at the service regarding what to do in the event of an abuse allegation being made at the service. The staff training records indicate that most staff have received recent training in Safeguarding of Vulnerable Adults, and training is planned for those who still need to attend this. Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27 and 30 Quality in this outcome area is poor. Improvements are being made to the environment to make the home safe and comfortable for the people who stay there. In addition to this, there are number of additional issues that have been identified as needing to be addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the building was carried out with the manager of the service. A lot of positive work has been, and is continuing to be carried out to improve the environment. The manager showed enthusiasm about work that had already taken place around the home, including the redecoration of the games room, refurbishment of some bedrooms and re-flooring of some areas. A new door has been put on the shower room in the first floor, and the bathroom on the top floor is being completed re-done, along with the roof and Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 17 ceiling. The manager said that people who use the service are not currently accommodated in the top floor bedrooms. An action plan details the work that has been contracted to occur, in relation to the ongoing requirement to address issues in the environment. In addition to the planned works, the following issues need to be addressed by the service: • Net curtains and curtains or blinds are needed in all bathrooms, in the top floor lounge and all bedrooms • Need to remove equipment stored in first floor hallway, which was an old television, bin liner and carpet cleaner • Toilet seat needs replacing in bathroom opposite bedroom 6 • Need to cover exposed pipe-work in room 13. • Need to box in pipes around stairs leading up to the top floor. • Top floor toilet needs to be redecorated and make good wall around toilet cistern and box in pipe-work • The flooring around the fire exit opposite the bathroom on the ground floor needs to be addressed as it is damaged and could be a trip hazard. • The pipe-work in bedroom 3 needs to be boxed in. The home is spacious and there is a relaxed atmosphere throughout the home. People who use the service say that the home is always fresh and clean, and that they feel it has improved since Southside Partnership took over. The staff are also positive about changes that have been made to the environment, including new furniture, re-decoration and new equipment in the games room. Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. Whilst improvements are being made to the recruitment and training information held about staff, this needs to be thorough and robust to ensure that risks are minimised to people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Feedback from people who use the service is that the staff generally treat them well, and that they feel they sometimes listen to what they say. During the inspection 12 staff files were looked at. Some work has taken place, and is ongoing to ensure that the files contain all the required information about the recruitment checks carried out on staff. The information contained varies between each file, where some do not have a photo, evidence of Criminal Records Bureau (CRB) check, some do not have a full employment history and some do not have copies of references. In some files a ‘staff information’ form says ‘original information held at head office’. However, these forms were seen to be incomplete for a number of staff, and not signed by the registered person, manager or representative from Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 19 the personnel department to say that they had seen and verified the information held at the head office. This does not ensure that the recruitment checks at the service are robust, and protect the people using the service. A requirement has been made to address this lack of information. The previous inspection required that staff receive training in a number of areas, including fire safety and food hygiene. This has taken place for a number of staff and future training planned in areas such as dealing with challenging behaviour and sexuality and relationships. The training records regarding each staff member need to be more organised, so that an individual log of training received, and planned, for each staff member is maintained. Professionals involved with the service say that they feel the staff usually have the right skills and experience to meet needs, but that they feel this could improve by both the permanent and agency staff having more training. Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. The manager is competent and understands the responsibilities of their role. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has worked for approximately six months. He demonstrates a good understanding of what is needed to develop the service and uses feedback constructively to prioritise areas requiring attention. He is also very enthusiastic and has a positive vision for the future of the home. The staff say that they get good support from the manager and that there is good communication at the service. Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 21 Records indicate that group meetings with people who use the service take place regularly, where issues such as the environment, menu, and day trips are discussed and planned. A staff meeting takes place every 4 weeks. The manager showed the current ‘resident feedback form’ that people who use the service complete at the end of their stay. This is in a user-friendly format, with pictures to reflect the questions being asked, such as: did you enjoy your stay? Is there anything you didn’t enjoy? Were the staff polite? Currently the person completes this with the assistance of staff, yet the manager said he recognises this is not the ideal, and that he is currently looking at ways of changing the format so that people can complete this no assistance. Surveys are also carried out with the relatives of people who use the service, and the responses varied. However, it is unclear as to how the responses are used to develop and make changes to the service, and more transparent evidence of this needs to be available. A management audit is carried out weekly by the manager or a team leader, so ensure that such areas as medication, fire checks, and health and safety checks are being carried out. Appropriate health and safety checks are carried out around the home, with records to demonstrate that up-to-date checks had been done on the fire system and fire safety equipment. Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 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 3 2 2 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 3 ENVIRONMENT Standard No Score 24 1 25 1 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 3 X Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 YA19 Regulation 14 Requirement The Registered Persons must ensure that there are ongoing reviews and assessment of each service users placement at the service and written documentation available to evidence this. The Registered Persons must ensure that the care plans detail all relevant information about each person using the service. The Registered Persons must ensure that a person-centred approach to care is used to enhance the care planning and record-keeping. People who use the service must be involved in planning their care, and this must be evidenced. The Registered Persons must ensure that the food provided is suitable to meet the needs and likes of all people who use the service, so that they are provided with food that is suitable. DS0000070866.V373146.R01.S.doc Timescale for action 28/02/09 2. YA6 15 31/03/09 3. YA7 12(4), 15 31/08/09 4. YA17 16(2)(i) 16/12/09 Hartfield House Version 5.2 Page 24 5. YA17 16(2)(i) The Registered Persons must ensure that opened jars of food are labelled with the date opened. This is to ensure that people using the service are provided with suitable and nutritious food. The manager must ensure that staff competency in handling medication is regularly monitored. The fridge used for storing medication must be kept locked at all times. The Registered Persons must address all environmental issues as detailed on pages 19 - 21 of this report. (Requirement still in timescale at time of inspection) 16/12/08 5. YA20 18 31/01/09 6. YA20 13(2)) 31/01/09 7. YA24 13(3)(4), 16(c),23 31/03/09 8. YA34 17(2) Sched 2 The Registered Persons must ensure that records relating to the recruitment of staff are held at the home to demonstrate that appropriate recruitment checks, including CRB checks, have been carried out prior to employment, or written confirmation held to verify that appropriate recruitment information is held by the organisation. The Registered Persons must ensure that an individualised training log is maintained to record the training undertaken, and planned for each staff member. 31/01/09 9. YA35 13(4), 18(1) (c) 31/01/09 Hartfield House DS0000070866.V373146.R01.S.doc Version 5.2 Page 25 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 YA1 YA13 Good Practice Recommendations Consideration should be given to producing the Statement of Purpose into a more user-friendly format. The service should ensure that people using the service spend their day as they wish, and that appropriate support is offered by the service to enable this. To record the maximum/minimum temperatures of medicines fridge using a suitable maximum/minimum thermometer to provide accountability for meeting the medicines licensed storage conditions and to maintain therapeutic effect. To provide a recent edition of the BNF for reference on medicines. A record should be maintained of whether each complaint has been upheld or not. The service should demonstrate how the feedback received from surveys informs improvements to the service. Hot water temperatures should be maintained between 40/43 centigrade. 3. YA20 4. 5. 6. 7. 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