Inspection on 11/06/08 for Heathfield Gardens

This inspection was carried out on 11th June 2008.

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

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

Other inspections for this house

Heathfield Gardens 25/06/07

Heathfield Gardens 12/12/05

Heathfield Gardens 02/08/05

Heathfield Gardens 17/01/05

Heathfield Gardens 06/09/04

Heathfield Gardens 17/09/02

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Heathfield Gardens 163-165 High Street Tibshelf Chesterfield Derbyshire DE55 5NN Lead Inspector Nancy Bradley Unannounced Inspection 11th June 2008 09:00 Heathfield Gardens DS0000002058.V366045.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 Heathfield Gardens DS0000002058.V366045.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. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heathfield Gardens Address 163-165 High Street Tibshelf Chesterfield Derbyshire DE55 5NN 01773 872229 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) a.buljeean@mgbcareservices.co.uk MBG Care Services Allison Stafford Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th June 2007 Brief Description of the Service: The home is situated within the rural community of Tibshelf, Derbyshire, which provides many local facilities. Many of the service users access these local facilities within the village. The home consists of two converted adjoining houses to provide one registered home, which provides nursing care for 10 service users with learning disabilities. There are two lounge/dining rooms and bedrooms situated on the ground and first floor. There is the provision of a minibus and local transport. The previous years inspection report is held at head office. The fees range from £685.57 to £1108.50 per week. Heathfield Gardens DS0000002058.V366045.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 was an unannounced key inspection and took place over a total of five hours. We spoke with the manager, care staff and people living at the home. The inspection activity during this site visit was to assess the service against the key National Minimum Standards and these are identified through the report. We looked at all the information that we received or asked for, since the last key inspection. This included the following: The annual quality assurance assessment (AQAA) that was sent to us by the home. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the home. Two people living at the home were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at support plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the individual. Additionally, time was spent in preparation for the visit, looking at the service history and the previous inspection report. Records were examined relating to the people living there and the general running of the home. There were nine people living at the home on the day of the visit, the home currently has one vacancy. We sent out nine “Have Your Say” questionnaires and we received nine completed questionnaires, from people living there who confirmed they were very happy at the home and were looked after by the staff and could not wish to live anywhere else. Only two people indicated they would like to speak with us. The staff completed questionnaires on behalf of the people living at the home. We received seven completed questionnaires from staff all were very positive about the home, were happy and enjoyed working there. We received a warm, friendly and enthusiastic welcome from the people living at the home. What the service does well: Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 6 The home provides good opportunities for the people living at the home with several of them taking holidays aboard. The home offers good choices about how they spend their day and provides individual support for the people living there. The care staff stated they are developing peoples’ independence much more then previously and this comes from the manager giving them support on a day-to-day base. Good communication between the staff, which ensures they are kept informed about changes to the care of the people they are looking after. The home was comfortable in appearance, was maintained to a good standard and set in pleasant surroundings. 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. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 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 Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that peoples’ needs are fully assessed and met prior to admission. This ensures that peoples’ holistic needs are appropriately met. EVIDENCE: People living at the home have been there for a long time and there have been no new admissions since the last site visit. The home provides care for ten people and at the time of the site visit they have one vacancy. The manager confirmed they have an admission pending. There was evidence on file to show that the care needs assessments of the service users were are being reviewed by the referring agency. Information in the AQAA details the home’s new admission procedure the manager confirmed she had been able to use this for the new admission. People are given an opportunity to spend time at the home and are allocated a member of staff to make them feel welcome. The manager has added the staff going to visit the previous home and to meet the person before they visit Heathfield. The manager stated this would help with building relationships. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 9 Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a care planning and review system in place, which ensures that people’s individual needs are met. EVIDENCE: During the visit care plans of two people who live at the home were seen. The manager for each person at the home had compiled the care plan and evidence was seen of care plans being reviewed on a regular basis. People living at the home who were case tracked had a detailed care plan, which was in accordance with their assessed need and formulated within a risk assessment. All care plans were detailed people’s individual lifestyle preferences and choices; the interventions prescribed by outside healthcare professionals were appropriate. Daily/nursing records are also maintained on each person who lives at the home. There was evidence to show that care plans are being reviewed on a regular basis. The manager currently reviews them on a monthly basis. The home has yet to establish a formal annual reviewing system with the referring agency. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 11 The detail and information in the care plans has improved since the last site visit and the home now has a good direction on how they are delivery care to people living at the home. We discussed with the manager how the home could develop and further implement changes to care. People living at the home knew who their key worker was and told us how they help them on a daily basis. The manager is looking to develop this role further. Care plans have been explained to the people living at the home and they have signed where possible that they agree and understand. In cases where they are not able to sign, family has done this. All of the staff have signed the care plans showing their commitment to people living at the home. Risk assessments were in place covering such issues as, people’s health and safety, physical health, nutrition, mobility, behaviour management and risks associated with social activities. Risk assessments were are also monitored and updated as required. We discussed with the home about people who live there having access to the local Advocacy Services. The manager stated that the relatives are actively involved in their care act on their behalf if required. Several of the families are responsible for their relatives’ finances. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were arrangements in place to enable people to maintain and develop appropriate relationships, and to participate in activities both in the home and outside in the wider community in accordance with their preferences and wishes. EVIDENCE: The care records of two people from the home seen provided detailed needs assessment and care planning information regarding their social, recreational, educational and occupational activities both within the home and outside in the community. Discussion with people from the home during the visit confirmed they were very happy living at the home and they liked the activities offered. They told us the home is taking them on holiday to Skegness Spain and, United States of America. Recent trips have been to Drayton Manor Park, Matlock and Twycross Zoo. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 13 Various photographs, which were around the home showed people having a good time and enjoying themselves. The relationships observed between care staff and people who live at the home appeared open and good-humoured. People at the home told us they have a close relationship with the staff who play an important part in their lives. The staff encouraged the people living at the home to take pride in their appearance and their dress sense is respected The daily routines are flexible with every one being able to make their own decisions about how they spend the day. The people living at the home are encouraged to be as independent as possible taking responsibility for some of the household tasks, like tidying their rooms and keeping the communal living area tidy. The majority of the people who live at the home are unable to work due to their level of disability. Several have attended adult education classes in the pass. Their personal goals, choices and preferences were identified and properly recorded risk assessments were in place for each person in relation to the activities they were engaged in. Holidays and day trips do not have risk assessments in place. People living at the home are involved in the planning of all activities during house meetings. As discussed with the manager the programme needs to be accessible to the people living there. Its current pinned up in the medical cupboard. Information on peoples’ records indicated that contact with family and friends was appropriate. Any restrictions on contact are recorded in care plans. People at the home can speak with family and friends by telephone. The home is due to have IT access shortly and they will have access to e-mail. This could further enhance people’s communication needs. Information in the AQAA showed that the home has also arranged social occasions for family and friends. From examination of the menus the home is providing a healthy well-balanced and nutritious diet. People at the home made positive comments about the meals and said their likes and dislikes are taken in to account. The new cook discussed with the people what they liked and disliked and worked a four-week menu around their preferences. During lunchtime everyone was given a choice of menu. We had lunch with everyone at the home. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples living at the home receive personal and health care support in a way, which promotes their independence and is in accordance with their preferences and wishes. EVIDENCE: Records seen and discussions with staff indicated that peoples’ health and personal needs were being met People living at the home were generally healthy and records showed that staff promptly contacted the appropriate medical services. People living at the home are registered and attended services within the community including doctor’s optician, podiatry, dentist, and audiologist. Discussions with the manager confirmed the home is looking to access the learning difficulties services from Ashgreen. The home maintains records of all hospital and doctors visits. The home maintains a record of peoples’ weight as part of maintaining a health lifestyle. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 15 The medication administration practices of the service were assessed. Peoples’ photographs were in place on medication administration records confirming their identity. The controlled drugs register was examined and this had been completed correctly. The storage of medication was looked at and was found to be satisfactory, this included medication stored in the clinical fridge, where fridge temperatures had been recorded to ensure this medication was stored at the required temperature. The medication is supplied from the local pharmacy. Discussions with the home indicated the pharmacy have not completed an audit of the homes’ medication procedures. The manager agreed to address this. Information in the AQAA and from discussions with the manager confirmed several of the people who live at the home have an end of life plan. The home is looking to ensure all the people at the home have a plan in place. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to safeguard service users’ welfare and ensure that their concerns are listened to and acted upon EVIDENCE: The complaints policy was seen and included a timescale of five days for a response to complaints. The complaints procedure is included in the service user guide. The registered manager confirmed they had not received any complaints about their service neither have we the Commission. The home holds regular meetings with people who live at the home. Some of the minutes of these meetings were seen and demonstrated that issues raised, were dealt with promptly and appropriately. People living at the home indicated that any concerns could be discussed with “Kimberley” the manager. The manager takes the minutes then uses a symbol format so the people at they home can fully understand the meeting. The compliant procedure is clearly displayed in the entrance to the home and in various prominent places within the home. The AQAA has been completed by the Operations Manager and makes reference to abuse and abuse awareness not safeguarding. The homes policy on the protection of adults was examined. Procedures for whistle blowing needs to be incorporated into the policy. The current policy makes reference to Nottinghamshire Abuse procedures, when the home should be adhering to Derbyshire’s procedures. The home has a copy of the Departments of Health guidance No Secrets Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 17 There has been no reported incident of Safeguarding of Adults since the last inspection. The AQAA shows Abuse awareness training is scheduled for 23rd June 2008. As discussed with the manager all of the homes’ staff should receive training in safeguarding. Staff training records and the AQAA indicate that all staff have received training on physical interventions. Records of people living at the home indicate that there has been reductions of incidents were staff have had to use physical intervention techniques. Their families administer the majority of people’s monies. Although the home has several are under Guardianship. The home was not ware of the actual number. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, well equipped and maintained, which prompts peoples’ independence. EVIDENCE: We carried out a full tour of the home, accompanied by the manager. All communal areas were seen. Peoples’ bedrooms were inspected with their agreement and all rooms had been furnished to their personal choice and were being personalised. The home was clean, well maintained, well furnished, equipped and well lit and heated. Where personal items, furniture and fittings have been removed for health and safety reasons has been risked assessed and included in peoples’ care plans. The home has had a new kitchen and people’s bedrooms were being decorated to their personal preference. House meetings indicated that people living at the home had contributed to the decoration of the home. All of the bedrooms are single with en-suite facilities. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 19 People living at the home stated they were happy with their bedrooms and the home. The tour of the building identified that carpets in some parts of the home have become worn. The manager confirmed that new carpets were on order. There are no other outstanding maintenance issues. The home was free of any unpleasant odours or smells on the day of the visit. The home has effective infection control procedures in place. Records indicated all staff had received training on infection control. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34,35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has recruitment and selection procedures in place to ensure that the appropriate staff are employed to care for vulnerable people EVIDENCE: Information in the AQAA indicated that there have been several staff changes since the pervious site visit. The manager confirmed that they have been successful in appointing new staff and now have a good compliment of staff. Direct of observation of the staff showed they worked flexibly to meet the developmental and social needs of the people who live at the home. The home operates a key-worker system and the staff spoken with during the visit were aware of the individual needs of the people living there. Rotas showed that five staff work in the day with two staff covering the waking night. Information received from the AQAA shows that the home has a total of sixteen staff. Currently the home has seven staff holding a NVQ level 2 or above and two working towards this, which gives them a sixty percent of care staff qualified. There are three registered nurses, a cook and housekeeper. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 21 The home has a recruitment procedure in place, which ensures that staff appointed are suitable to work with vulnerable people. Several staff personnel records were examined which confirmed that thorough employment checks were carried out. All new staff are required to provide two references, a full employment history, have a clear Criminal Records Bureau clearance and complete a probationary period. As part of providing a full employment history applicants need to provide an accurate chronology of their employment history with the days date month and year. From recent staff recruitment records examined, applicants were only providing the year in one instance. This area of shortfall were discussed with the registered manager The staff personnel records were well presented From discussions with the Manager and from examination of records the home is providing good training and development opportunities. Details in the AQAA. All staff have a personal development plan. Records examined and discussions with the staff confirmed that the home has a formal structure for supervision of staff. Annual appraisals are due. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally well managed; with staff seeking the views of the people ensuring the home is run in the best interest of the people who live there. EVIDENCE: A new manager has been in post for about one year and is the process of submitting her application to us for registered manager. The manager stated she has a relevant job description setting out her roles and responsibilities. The manager has a number of years experience in the care sector and has a qualification in mental health. Completed questionnaires stated the manager was approachable and supportive and open to discussion. The manager has yet to complete a recognised manager’s award. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 23 The manager stated that a process for monitoring care and services provided has been established and is in line with the policy operated within MGB Care Services Ltd. The AQAA indicates there is regular feedback obtained from questionnaires house meetings and regulation 26 visits. We were shown easy read questionnaires given to people living at the home. Also completed questionnaires from family and stakeholders about the quality of care provided by Heathfield Gardens. A sample of service/maintenance records was examined (including gas and electricity services) and there was confirmation that all the equipment had been properly maintained. Evidence of checks having been carried out was provided to us by way of the AQAA. Systems were in place for the monitoring and maintaining the hot water temperatures. These were examined and found to be within a safe range. The home has a valid LegionElla certificate. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 3 12 2 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 2 X 3 X X 3 X Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement Care plans must be formally reviewed at regular intervals and be clearly shown as such to ensure people needs are fully met. Detailed risk assessments must be complied on all outside activities and holidays to ensure people are fully protected. The home must compile an end of life plan for all of the people who live there. The homes policy on adult protection must be revised and updated to reflect current practice. The manager must submit her application to the Commission for Social Care Inspection for Registered Manager. This is a previous requirement. Timescale for action 31/10/08 2. YA9 15 31/08/08 3. 4. YA21 YA23 13 and 17 13 31/08/08 31/08/08 5 YA37 7 31/08/08 Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. Refer to Standard YA4 YA6 YA20 YA24 YA23 YA34 YA34 YA37 Good Practice Recommendations The visit staff make to prospective new people should be shown in the admission procedure. Key workers should be included in the review process. The home should request the local pharmacy undertake a medication audit. The home should continue with its refurbishment plan. All staff should undertake a refreshing course in the Safeguarding of Adults All applicants should provide the days date month year when providing a full employment history. All staff interviews should be fully recorded and include questions and answers. The manager should complete a recognised managers award. Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Heathfield Gardens DS0000002058.V366045.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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