Inspection on 06/06/06 for Henry Street Residential Home

This inspection was carried out on 6th June 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Henry Street Residential Home 27/11/08

Henry Street Residential Home 06/12/07

Henry Street Residential Home 28/06/07

Henry Street Residential Home 28/02/06

Henry Street Residential Home 15/12/04

Henry Street Residential Home 05/07/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Henry Street Residential Home 21 Henry Street Debenham Stowmarket Suffolk IP14 6RH Lead Inspector Claire Hutton Unannounced Inspection 6th June 2006 10:30 Henry Street Residential Home DS0000024412.V294418.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 Henry Street Residential Home DS0000024412.V294418.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. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Henry Street Residential Home Address 21 Henry Street Debenham Stowmarket Suffolk IP14 6RH 01728 861122 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.mencap.org.uk Royal Mencap Society Mr Richard Baker Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: Henry Street was first registered as a care home for four people with learning disabilities in 1989. It is a purpose-built bungalow situated in a residential housing area on the outskirts of Debenham, Mid Suffolk. The home is managed and staffed by Mencap but the property itself is owned and maintained by Sanctuary Housing. The building is spacious and simple in design and layout. It incorporates lounge and dining facilities in addition to single bedroom accommodation. All areas of the home are wheelchair accessible. The home also has the advantage of a spacious secure garden and small sensory room. The home has easy access to local shops and amenities including a leisure centre, post office, pubs, café and public transport. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that focused upon the core standards relating to Adults (18 – 65). It took place on a weekday between the hours of 10.35am and 5.15pm. The process included a tour of the building, observations of staff and service user interaction, and the examination of a number of documents including residents care plans, medication records, the staff rota, recruitment, training records and records relating to health and safety. The report has been written using accumulated evidence gathered before and during the inspection. Three completed comment cards were received back from relatives/visitors and four completed surveys were received back on behalf of the residents by care staff and acting manager. Throughout the day the inspector met all of the residents, most of whom had a high level and specialist communication needs, and spoke with three members of staff on duty. The manager was on duty having recently returned from a three-month absence from the home. The area manager also visited during the inspection and was spoken with. What the service does well: What has improved since the last inspection? There has been significant improvement in the care plans. A full assessment of need for individuals has recently been completed along with action required by staff to support individual residents. A red file for each resident has been developed that is entitled ‘support plan’. This folder contains the key information that staff require. Risk assessments were seen to be in place with evidence of review. A revised procedure for handling residents’ money was seen to be in place. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 6 Food hygiene guidelines were seen to be adhered to as were the servicing and fitting of fire extinguishers. Evidence of planning for staff to attend training on protection of vulnerable adults (POVA) was seen. 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. Henry Street Residential Home DS0000024412.V294418.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 Henry Street Residential Home DS0000024412.V294418.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 and 5 People who use this service can expect to have their needs and aspirations assessed. People who use this service can expect to be provided with information relating to a contract, but not all parties may be aware of the content of this document. EVIDENCE: The resident group at Henry Street have been there a number of years and there have been no new residents admitted for some time. During the last three months a full needs assessment has been completed on all four the residents at Henry Street. Evidence of two completed assessments were seen. These had been completed by keyworkers at the home with the individual residents and support in completing them was given by the acting manager at that time. The format used was a model developed by Mencap nationally. Each assessment contained a photograph of the resident with their individual details and then each section such as healthcare, personal care, food and drink, social and communication etc was completed. Each section had a description of need. The contract which includes terms and conditions was revised in December 2005. Evidence was seen of two ‘licence to occupy’. This was a document that was developed by Sanctuary Housing and Mencap and set out the terms and conditions including fees. The Area Manager had signed these for Mencap, but the resident or their representative had not signed them. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 9 A more informative pictorial document was in each person’s file that the manager stated was gone through with the resident concerned. The local authority had placed each person at the home. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use this service can expect that their needs, choices and decisions will be known, recognised and respected by staff, whilst taking account of assessed risks. EVIDENCE: There has been significant improvement in the care plans. The assessment of need for individuals has recently been completed along with action required by staff to support individual residents. A red file for each resident has been developed that is entitled ‘support plan’. This folder contains a pen picture of the individual. This is a brief introduction that has been written in the first person about the individuals’ likes and dislikes and how they relate to the world and people around them. The keyworker designated is identified on the front cover. This also contains each element of care and support individuals require and sets out clearly the actions required by staff to meet the needs of the individuals. Risk assessments were seen to be in place with evidence of review. In one file there were six risk assessments and for another resident there were ten risk assessments. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 11 For the safety of residents the kitchen door was bolted when not being supervised by staff, but when staff were supporting an individual in the kitchen they were allowed access thus ensuring their safety. This was part of the risk assessments seen and the infringement of freedom was documented and in the best interests of the residents concerned. In relation to decision-making records seen, observations made and staff spoken with indicated that resident’s are supported appropriately so that they can make decisions about their lives. Day to day decisions about what to eat and what to wear were respected and the choice could be offered in a meaningful way. Staff had training in and were committed to working within a ‘Person Centred’ approach and had a good understanding of residents needs, likes and dislikes. Some staff had been working with the residents for several years and knew them well. Residents on the day had chosen to go for a picnic, a member of staff was seen to access individuals money on their behalf in order that they may have money for the trip planned. Wider decisions relating to residents finances have been detailed under standard 23. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 People who use this service can expect to lead a lifestyle that they choose by participating in the many opportunities presented to them for personal development, leisure family involvement and mealtimes. EVIDENCE: Records seen, staff spoken with and observations made indicated that residents are encouraged to develop and maintain independent life skills. The resident’s records that were examined included comprehensive information about the individual’s skills/abilities and the level of support required in a wide range of areas. They also evidenced that the home supports residents to engage in appropriate leisure activities. Though this may be more limited on a weekend when there tends to be less staff than during the week. The residents at the home have individual plans for daily activities. This varies from attending a local authority day service five days a week to accessing that service once a week. The facilities at a local charity day service are also accessed as well as the wider community. The previous day a trip to Felixstowe had taken place and on the day of inspection three residents went for a picnic in Abby Gardens in Bury St Edmunds. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 13 Two cars were used to transport residents and staff. The residents were said to be quite well known in the village community by using the facilities offered. Three completed comment cards were received back from relatives/visitors. These were positive in relation to feeling welcomed at the home and able to visit relative/friend in private. Positive answers were also received in relation to being kept informed about important matters and being consulted on decisions if their relative/friend was unable to decide. The manager spoke about forthcoming reviews and said that relatives would be invited to attend and able to participate appropriately. In relation to meals and meal times, a menu of what had been eaten by individuals was kept on the fridge. This was due to choice being offered at the point a meal is decided upon. That evening the main meal was minced beef with vegetables and noodles, but one individual chose to have a cheese sandwich. The weekly shop was said to be done regularly on a Thursday at a local supermarket, but in between time they use the local village store. Residents were able to part take in the weekly shop if they chose. Food stocks in the cupboards, fridge and freezer were good and able to offer a choice. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 People who use this service can expect to receive sensitive and flexible personal support and have their health needs met. In relation to medication residents may not be protected by the procedures currently in place. EVIDENCE: From discussions with staff, observations made and known wishes expressed in care plans residents at Henry Street are provided with a sensitive and flexible approach to personal support. One individual has a designated person that works on a one to one basis with them and for one other resident the home had just recruited a new staff member to work as a one to one. In relation to health care each individual had their health needs identified and the associated professionals detailed in their plan, this included GP’s, community nurses and outpatients appointments with specialists for learning disability. There was evidence of monitoring of a health condition such as epilepsy by staff, with records duly completed when required. A medication profile for each resident had been developed that listed medication prescribed, the reason why it is taken and possible side effects for staff to be aware of. Medication was examined. The home uses a monitored dosage system that is dispensed from a local chemist with printed medication administration records (MAR) sheets. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 15 The MAR sheets currently in use were examined and found to be appropriately completed. A sample audit was able to be undertaken of one persons medication and records were correct. However upon closer inspection of previous months (April/May) the MAR sheets had not always been appropriately completed. There were gaps in the administration section and the return of medication section. Therefore, a judgement could not be made as to whether residents did not receive their medication or staff had forgotten to sign. It would be good practice for the manager to periodically audit medication and sign the MAR sheet to denote this and for them to periodically supervise staff administering medication in line with the home’s procedure to deem them still competent. Also there should be a sample of staff initials to identify staff who administer medication. Three staff on duty confirmed that they had medication training. There was evidence to support this in staff files, but not in the case of one individual. This was discussed with the manager who agreed that refresher training would be undertaken. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Residents cannot be assured that they are entirely safeguarded from abuse or harm. EVIDENCE: The home have a complaints procedure in place and a copy was displayed at the home. This document is entitled ‘How to talk to Mencap’. From feedback from two relatives/visitors they were unaware of how they could make a complaint is they so wished. This was discussed with the manager who agreed to distribute the Mencap leaflet to all relevant parties. They believed that as the residents had been at the home for so many years this would be a beneficial reminder. Since the last inspection there has been two potentially serious complaints made. These were taken seriously by the organisation and an investigation undertaken. The outcome was that there was no case to answer, as there was insufficient evidence. The CSCI is satisfied in the way these matters have been dealt with. However, a record of all complaints made and the action taken must be kept in the home. The home had a file entitled complaints log, but this only contained blank forms awaiting completion. At the previous inspection it was reported ‘Two staff spoken with said that they had not undertaken Protection of Vulnerable Adult training and were not familiar with the local authority guidelines on adult protection.’ At this inspection staff had yet to undertake training, but dates have been planned in June and July. Staff were aware of these plans, but one member of staff spoken with was unable to travel the distance required to the training course. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 17 Three staff files examined found that Criminal Record Bureau checks were in place. Records seen and discussion with the manager confirmed that despite a recommendation made at the last two inspections concerning residents finances the manager continued to act as the appointee for all residents and was the sole signatory on their building society accounts. The inspector also noticed that while records of all financial transactions were held they were not independently audited. Records also evidenced that the home holds cash on behalf of residents. On the day of inspection cash held was locked away but did not have the facility of a safe as previously recommended. The procedures in place for handling residents money had been reviewed, however upon examination of records staff were not following the procedure in place. The procedure called for double signatures and this was not routinely completed. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30 Residents can expect to live in a clean and comfortable environment. Furthermore, they can expect to have a room of their own that reflects their needs and interests. EVIDENCE: The home is spacious and simple in design and layout. Communal areas included a lounge, dining room, kitchen, small ‘relaxation’ room, bathroom and a shower room. All areas had appropriate facilities and were furnished with comfortable ‘domestic’ type furniture. There was also a small office that ‘doubled up’ as a staff sleep in room. Although generally well decorated there is a need to have the wall in the laundry room, at the back of the washing machine made good, now that the new machine is installed. The laundry room must be easily cleaned. Therefore this area should be tiled or painted with a washable paint. All residents had their own single bedrooms. One of the four bedrooms was seen with the permission of the individual resident and it was decorated in a way that reflected the resident’s personality and interests. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 19 On the day of inspection all areas seen were clean and odour free. A discussion was held with the manager about transportation of soiled linen. This is currently placed in a laundry basket used for all clothing. A discussion was held around the purchase of alginate bags to prevent cross infection and spread of infection. The manager agreed to this recommendation. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Residents can expect to be supported by appropriate ratios of care staff but they cannot be certain that those staff are appropriately qualified. EVIDENCE: The staffing roster was examined and showed that currently there are two staff on duty very early in a morning starting at 6am. A third member of staff comes on duty at 9am. During the week one resident goes out to day care each day, therefore the staffing on a week day is one to one for the three residents at the home, up until around 4pm. The late shift tends to have two staff members on duty as does the shifts at weekends. There were times at a weekend when a third member of staff was on duty. This tended to be a Saturday. A discussion was held with the manager and staff separately about the deployment of staff as in the comments cards from residents and one relative, they questioned if there was always sufficient staff available. The manager believed there was always sufficient staff available, even at a weekend. One factor that is due to change imminently is the employment of a one to one carer for one of the residents for 35 hours a week. This post had been appointed to and CRB checks and references were awaited. Therefore it would be possible to offer more flexibility around weekends as suggested by the person who currently completes the rosters. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 21 The high usage of agency staff in the previous few months has now decreased to a lesser level. The recruitment records for three staff employed were examined. There was evidence of all the required checks in place. The manager also felt it good practice to have staff read and sign a confidentiality statement as the home is in a small village setting. From the three staff files examined there was evidence of regular supervision, induction training completed and a training plan in place for the coming year. Training planned included the protection of vulnerable adult training that was made a requirement at the last inspection. One certificate for NVQ was seen and a further member of staff stated they had achieved NVQ, but no certificate was available. The manager was rather vague about how many staff planned to commence NVQ in the coming months, but believed it to be more than two staff members. However, there was no supporting evidence to confirm this. This was the same information that was given at the previous inspection. One staff file examined did not contain any evidence that the staff member had received training in administration of medication. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42 The management of the home is improving, and previous shortfalls are being addressed. The quality assurance process is set to test this assertion. EVIDENCE: The registered manager of Henry Street has the appropriate experience to work with adults with a learning disability having worked in this area for several years. They had started their NVQ 4 and the registered managers award, but they have run out of time and funding from the current course providers. The manager stated they had completed 4 units that have been verified. Upon discussion they agreed to find another training provider and enrol promptly and then notify the commission of the expected timescale for obtaining the relevant qualifications. The manager states they have no other formal qualifications that relate to care. However, they stated they have obtained the relevant training courses that the care staff have obtained and that hey have a training and development plan in place. There was no evidence available to verify these points made. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 23 Over the last three months the manager was absent from the home and an acting manager managed the home. Both the returning manager and staff confirm that this situation worked satisfactorily. The manager received a week’s handover. At the last inspection it had been reported that ‘there were issues of conflict within the team and the morale amongst the staff group seemed low’. Three staff spoken to at this inspection either said morale was good or acceptable at the moment and that they felt the situation was set to improve. The team had a team-building day in March 2006 and the area manager attended the last two team meetings at the home. There have been four team meetings held since November 2005, minutes were kept and available for inspection. In relation to meetings for the residents to express their views on the running of the home, these had previously been said not to be very successful due to only one resident able to partake verbally and other resident chose not to remain at the meeting. Therefore, the manager explained that in the coming year four dates had been planned and a meeting would be offered on those days. This was documented in a file. What the manager believed to be more beneficial was reviews for individuals where they and their representatives could express any views about the home. A review for all residents was to be held over two days in June 2006 with the placing authority. The commission had recently received a copy of the Regulation 26 report for April 2006, but had not received one for February and March. A copy was at the home and the manager gave a copy for the commissions’ records. In addition the home will receive a service review conducted by Mencap once every three years. This will start on 12th July 2006 and will be conducted by a senior manager from another area. Matters relating to health and safety were examined. Records and checks were in place for fire alarm, emergency lighting and extinguishers. The fire risk assessment was completed in 2001. Control of Substances Hazardous to Health (COSHH) assessments were in place and available to staff. Electrical tests were in place for the hard wiring and portable equipment. Periodic testing of temperatures for food storage and bathing water had been taken by staff and documented. The manager was able to evidence heath and safety training for staff. Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes 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. Standard 1. YA5 Regulation 5 (3) Timescale for action Where the local authority has 31/07/06 placed a resident the registered person must supply a copy of the agreement to the resident and/or their representative specifying the arrangements made. The registered person must take further steps to ensure records for the administration and disposal of medicines are accurately completed at all times. A record of all complaints made and the action taken by the registered persons must be kept at the home. The registered person must ensure as far as practicable that they do not act as the agent for service users. The Registered Person must ensure that all staff follow the Policies and Procedures in place for the safe handling of service users monies. The Registered Person must DS0000024412.V294418.R01.S.doc Version 5.1 Requirement 2. YA20 13.2, 13.4 31/07/06 3. YA22 17(2) schedule 4 (11) 20 (3) 31/07/06 4. YA23 31/07/06 5. YA23 13(6) 31/07/06 6. YA23 13(6) 31/07/06 Page 26 Henry Street Residential Home 7 YA37 9 (2) (b) (i) ensure that all care staff receive adult protection training and are familiar with local authority procedures. (This is a repeat requirement from 28/01/06) The registered manager must notify the commission about timescales for becoming appropriately qualified. 31/07/06 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 YA23 YA35 Good Practice Recommendations There should be a safe installed to appropriately safeguard resident’s money. The home considers the provision of refreshment training for those who have undergone training more than 12 months previously. Certificates of attendance should evidence this. The competence of staff members when administering medicines should be monitored on a regular basis via supervision. A record should be kept of staff initials to help identify by whom medicines have been administered. The manager should periodically audit medication and sign the MAR sheet to denote this. The use of alginate bags should be used to transport soiled laundry to the washing machine. The laundry walls should be impermeable and readily cleanable. The fire risk assessment should be reviewed. 3. 4. 5. 6. 7. 8. YA20 YA20 YA20 YA30 YA30 YA42 Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Henry Street Residential Home DS0000024412.V294418.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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