Inspection on 29/04/05 for Holmbury Dene

This inspection was carried out on 29th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holmbury Dene 08/08/08

Holmbury Dene 08/10/07

Holmbury Dene 18/05/06

Holmbury Dene 08/12/05

Holmbury Dene 22/12/04

Holmbury Dene 02/08/04

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Chatsworth Care - Tudor Lodge

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Holmbury Dene 2 Lawrie Park Road Sydenham London SE26 6DN Lead Inspector Sean Healy Unannounced 29 April 2005, 9.30 am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Holmbury Dene Address 2 Lawrie Park Road Sydenham London SE26 6DN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8778 7700 020 8778 9437 Providence Project Mr Maurice Gregory OSullivan CRH care home PC care home only 10 Category(ies) of LD learning disability registration, with number of places Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: This home is registered for 10 persons with a learning disability of whom up to 3 may also have a physical disability Date of last inspection 22 December 2004 Brief Description of the Service: Holmbury Dene provides care for up to 10 people with learning disabilities, up to three of whom may have a physical disability. The support offered includes mental health and management of challenging needs. The home is staffed on a 24-hour basis, consisting of a manager, two assistant managers and up to seven full time staff. The staff levels vary, depending on the number of service users living in the home at any one time. The home provides respite care for service users who live in the community with carers, and for service users awaiting more permanent placement. The home is also the emergency placement and assessment centre for people with learning disabilities in Lewisham. It is a large two and a half storey building close to Sydenham train station and local shops and services. The area is also well serviced by buses to central and south London. There is accessible off road car parking space for up to 7 cars to the front and side of the building. The garden is accesssible from the dining room. The ground floor is wheelchair accessible, consisting of four single bedrooms, a reasonable sized kitchen, a mid-sized dining room, a large lounge looking on to the front of the building, one fully accessible shower room/toilet, one fully accessible bathroom and the staff sleepover room. The first floor contains three single bedrooms, two bathroom/toilets, a lounge area and the staff room. There is also a self contained flat on the first floor currently not used for accomodation. The second floor has a room used for volunteers. There are currently six service user vacancies. Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out over two half days on the 29th April and 6th May 2005. This was facilitated at the home’s request as the manager and service users had planned to go out on the first day of the inspection for training and activities. The home’s manager was present and took part in the inspection process. The manager provided complete cooperation during the inspection. The current registered manager has undertaken other duties for the registered provider and the new home manager has applied and interviewed for the position of registered manager with CSCI and was awaiting a decision at the time of the inspection. The inspector interviewed three staff individually and met informally with two service users. Comments from all are included in this report. The inspection included a tour of the home and examination of records on care plans and building maintenance records. Complete staff records regarding recruitment, training and supervision are maintained at the central office and were not available for inspection. During the inspection staff interaction with service users was observed to be very regular and conducted in a respectful manner. What the service does well: What has improved since the last inspection? The home’s Statement of Purpose has been revised and the Service Users Guide has been produced in a more understandable way using pictures called “Widget”. One service user who wanted to stay in the home on a more longterm basis has had this formally agreed. Documents given to service users now include details of the room they will have and the shared facilities, which will be available. The home now has established a system for keeping contact with Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 6 service users who leave the home, but who will be regularly returning for respite support. Care plans are now dated and signed by the service users who are now given a copy of their plan. Some work has been done to improve the system for involving service users in the day-to- day running of the home, but more work is needed. Arrangements for managing medication have been improved. Adaptations have been made to a round floor bathroom to install an accessible shower for service users with mobility support needs. Two more permanent full time staff have been recruited and the new manager has decided to stay on a long-term basis and has interviewed to become registered care manager. 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. Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 and 5 The home’s revised statement of purpose is not available at the home to enable current and prospective users and relevant other people to make an informed choice about where they live. Service users are not fully informed regarding contractual terms and conditions without which they are not fully aware of their rights. Service users at the home are only admitted on the basis of having a full assessment of need, but assessments do not comprehensively include individual communications abilities and needs, without which they cannot fully know that the home can meet their needs. EVIDENCE: As required at last inspection the home has revised it’s Statement of Purpose, which the home’s manager was clearly able to describe and discuss, but a copy was not available at the home. Staff and service users interviewed were not aware of details of changes made. It was not clear from discussions with the manager whether copies were distributed by the relevant referring agencies to prospective service users to enable them to make an informed decision about whether the home meets their needs prior to becoming involved in a moving in process. Having the Statement of Purpose available and understood by service users is particularly important to this home as there is a regular movement of service users due to the nature of providing respite support (refer to requirements). The home has in place a revised Service user guide, which is produced in accessible format using “Widget” picture graphics. One service user who has Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 9 lived in the home for a long period was not sure of why other service users don’t stay longer at the home and did not understand the “Widget” picture system. Some work needs to be done to ensure that individual service users fully understand the home’s service user guide in the format that it’s produced (refer to requirements). The home has a comprehensive assessment for all service users prior to admission. This includes a person centres assessment for some service users who receive support from challenging needs professionals. However, all assessments do not comprehensively include all service users’ individual communications needs, which can result in their not understanding whether and how the home will meet their assessed needs, and also could be a factor in triggering challenging behaviour, due to lack of understanding (refer to requirements). The home does not have a written and costed contract between the home and the service user. The home is funded on a block contract with the local authority and has in place a contract with that authority. This contract does not specify all required areas such as rooms to be occupied or fees to be paid and service users do not have a copy. This was confirmed by the manager. There is an enhanced need to ensure that all service users are in possession of a contract, given the short term stay arrangements for some service users, while one service user has a formal arrangement to stay in the home long term. This was also a requirement of last inspection (refer to requirements). It was a requirement of the last inspection that one service user’s long-term placement at the home be reviewed by the funding authority regarding the appropriateness of a long-term placement in a respite/short-term placement. This has now been done with the involvement of the service user, family and other relevant professionals. All agreed that the placement is appropriate. The service user confirmed agreement with this decision. Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 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 standard(s) 6,8,9 and 10 Service users plans are generated from local authority assessments, but assessed and changing needs are not consistently reflected in individual plans, which presents some risk to service users. The home does not consult with service users adequately regarding planning and participation, which prevents their full involvement in making decisions about their lives. Service users information is handled appropriately. EVIDENCE: The home provides individual plans for service users, which are agreed with the service user and other relevant people such as family and professionals. A number of service users receive input from the challenging needs team and have good person centred support plans in place, including good risk assessments. However, other service users who do not receive this support have not got adequately comprehensive plans and risk assessments in place. For example, one service user’s assessment said that he liked to go out shopping with support, but his individual plan did not describe the risk involved in doing this or provide guidelines for staff regarding his support in this area. The manager accepted that these areas need to be addressed through training for staff, and in reviewing all service users plans and risk assessments (refer to requirements). Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 11 The manager confirmed that though a key-worker system is in place, which is comprehensive, it is not being properly implemented. This causes problems in following through on agreed plans and in monitoring degrees of success. It also makes it difficult to provide good information for reviews and most importantly can leave service users lacking in focused support to achieve their personal aims for achievement and involvement (refer to requirements). There is a lack of evidence to demonstrate consultation with service users regarding planning daily activities and regarding the home’s and organisation’s policy review. The home manager stated that service users are now consulted more on daily activities. The recent review of the home’s Statement of Purpose was done without consultation with all of the home’s current service users. There is a need to improve service user involvement in these areas of activity (refer to requirements). There is now a system in place for key-workers to maintain contact with service users who are consistent respite care users and care plans are now dated and signed by the service user as required at last inspection. A service user said “staff are very good at keeping quiet about my information and don’t talk about me.” Service users files are now being kept in a locked cupboard. Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 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 standard(s) 12, 14,15 and 17 Service users are able to take part in appropriate activities including cultural, leisure, personal development and work. The home helps service users to maintain and develop personal and family relationships, and promotes good health through a balanced and varied diet. EVIDENCE: Due to respite placements often being short-term for many service users, receiving support for long-term goals such as long-term training or employment can be difficult, but where possible the home will support longterm objectives. One service user has a part time job in an office and is supported by staff to understand the requirements of the job and attends independently. He commented that “ I am very happy working at the office and the staff help me if I need it.” Work is being done with a service user who has been at the home for six months to identify appropriate training/work activities. Service user individual plans include maintaining activities in training and employment; recently the home has started to maintain contact with service users who have left the home who may be returning for continuing respite Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 13 care. It is part of the support provided to help service users manage their finances and benefits if needed as part of the individual’s assessed need. Leisure activities are maintained and the key-worker system tries to facilitate this. However, some further work needs to be done to ensure that individual needs in this area are more systematically planned on a weekly and daily basis and that systems for recording and monitoring activities are improved. One service user said that “ I want to go on holiday again this year but I’m not sure who’s going to help me or where I can go to” (refer to recommendations). The home’s records show that good information is recorded on admission regarding details of service users’ family and friends. There is regular weekly contact from family and friends and developing relationships is encouraged. The home offers good nutritious meals and attention is given to individual requirements such as dietary needs and personal preferences. Choices are offered on a daily basis and service users are involved in shopping and cooking. One service user said “ the food is good and I can eat what I like.” Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 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 standard(s) 20 and 21 Service users do control and administer their own medication where appropriate and are protected by the home’s policies and procedures. Ageing, illness and death issues are handled sensitively and with respect in consultation with service users EVIDENCE: It was a requirement of the last inspection that the systems for recording and monitoring medication be more consistently used by staff to ensure service user safety. This has now been done and there have been regular discussions at team meetings and in staff supervision. There was also a requirement to address issues of ageing illness and death with a long-term service user. The home manager and the service user’s keyworker have begun sensitive discussions with the service user and work is ongoing regarding this issue. Service users’ abilities and support needs regarding medication are included as part of the assessment process prior to admission. There is a comprehensive medication policy in place outlining processes for receiving, storing, administering, recording and disposing of medication, which is now consistently followed by staff. Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The service users feel that their views are listened to and acted on regarding concerns and complaints EVIDENCE: The home has a detailed complaints policy in place outlining how complaints and compliments are to be handled, including descriptions of what a complaint is, who can complain, who to complain to, and a timescale of 28 days within which complaints will be fully responded to. All of the staff interviewed were aware of the policy details and demonstrated a sensitive and listening approach in responding to complaints. Staff said they would always refer complaints immediately to a senior manager, either the home’s manager or the on call manager. A service user said:“ I trust the staff to listen to me when I am worried.” Another confirmed “I have been told by the manager how to complain if I want to.” There have been two complaints made to the home in the past 12 months and both have been fully substantiated. Both were dealt with within 28 days. Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 27 Service users live in a homely, safe and comfortable environment; toilets and bathrooms provide sufficient privacy and access for current service users. However, the home does not have a clear policy statement on how it will meet requirements of the Disabilities Discrimination Act 1993, which may allow discrimination regarding access to occur if not addressed. EVIDENCE: The home has individual single bedrooms for up to ten service users. Four of these are on the ground floor providing easy access. There is a kitchen, living room and dining room, an accessible shower room and accessible bathroom on the ground floor, providing good facilities for service users with physical disability support needs. It was a requirement of the last inspection that work was to be done to create an adapted shower room for service users who preferred showers rather than baths. This has now been done. The home has a further two bathrooms on the first floor. There is access to the garden and car park area via the dining room on the ground floor, which is accessible for wheelchair users. The home is well maintained and decorated in consultation with service users. A service user said that he is asked about colours when the home is being decorated and stated “ I am very happy with my bedroom.” Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 17 It was a requirement of the last two inspections that the registered manager must submit details to CSCI on how the home intends to meet requirements of the Disabilities Discrimination Act 1995. This was not done and the manager stated that the organisation does not have a policy on how to achieve this. As the main function of the service is respite care it with many service users regularly coming in and out of the service, it is important that the home management address this issue, particularly to ensure that new service who may have disabilities are not discriminated against (refer to requirements). Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 and 35 Service users are currently supported by competent staff in sufficient numbers to facilitate support for the four service users currently using the service. However, staff qualifications and the fluctuating staff levels do not ensure that service users needs will continue to be met. EVIDENCE: The home has in place adequate training and induction systems to meet Sector Skills Council requirements, and staff are experienced in working within the learning disabilities field of support. It was a requirement of the last inspection that efforts are made to fill vacant staff positions. Two new staff were recruited in January 2005. The home provides support regarding challenging behaviour and mental health support and has good relationships with all relevant professionals. There are good intervention strategies and care plans in place demonstrating this. The home accesses training support from the provider organisations training co-ordinator and from the local authority training team. The home is registered to support up to 10 service users, but regularly it has only four service users living there at any one time. In response to this, the home’s management regularly move staff in and out of the service depending on service user levels. Consequently, there is a difficulty in maintaining staff who are qualified at appropriate NVQ levels in care, and also presents a problem in ensuring consistency in staff who know the service users. The home has a staff team consisting of a manager two assistant managers and up to Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 19 seven support staff. The home’s manager confirmed that currently none of the staff have achieved NVQ level 2 in care, but realises that this needs to be addressed and has ensured that five staff are now on an NVQ course. 50 of the staff team should have achieved this qualification by 2005 and this is now an issue requiring priority action (refer to requirements). The organisation had requested that NVQ training requirements should be related to the whole organisation and not individual registered care homes, but it has been confirmed that NVQ training requirements must be related to each individual care home. Staff indicated that there have been problems in achieving the required NVQ award due to a lack of organisational momentum and changes in management. Staff must be supported to carry out the necessary fieldwork and training to achieve the required NVQ award. Staffing levels relate well to current service user needs, but there is a need to define baseline staffing levels below which levels should not fall regardless of the number of service users receiving a service, to ensure staff stability when new service users are admitted. This must also ensure that the qualified staff levels do not fall below 50 of the full staffing establishment (i.e. there must always be a minimum of four support staff who are experienced and have been trained to NVQ level 2 in care - refer to requirements). Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39 and 43 The home is well run, but the home manager does not yet have the required qualifications to ensure the ability to competently manage and develop the staff team. Adequate systems are not in place to seek service users’ views on the management of the home. Service users benefit from competent and accountable management of the service. EVIDENCE: The current manager has now applied to become registered care manager and is awaiting the outcome of interview with CSCI. This was a requirement from last inspection. The manager has now enrolled on the NVQ level 4-award course, which will take a minimum of 6 months to complete (refer to requirements). The manager explained that the requirement from last inspection regarding ensuring appropriate quality assurance tools and systems are in place, to seek the views of service users and to assess and improve it’s own service, has not been addressed. It is important that regular, effective means of canvassing service users’ views and acting on them are implemented as soon as possible. Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 21 It is especially important for this home that these are used regularly, to ensure that new service users who stay at the home for shorter periods are also included in this system (refer to requirements). The home now has a comprehensive budget and an agreed plan for refurbishment and redecoration in place in response to a requirement from last inspection. Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 x 1 Standard No 22 23 ENVIRONMENT Score 4 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x 2 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 3 x x x Standard No 11 12 13 14 15 16 17 x 3 x 2 3 x 3 Standard No 31 32 33 34 35 36 Score x 2 2 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Holmbury Dene Score x x 3 3 Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x x 3 G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA 1 Regulation 4.2 Requirement The registered manager must ensure that a copy of the homes revised Statement of Purpose is sent to CSCI and copies are also made available to the service users, their representatives and referring agencies The registered manager must ensure that all service users assessments include details of preferred communication methods and ensure that the service users guide and all other information is presented in a format that is best understood by them The registered manager must ensure that all service users plans include the implementation of all areas of assessed support need, especially regarding skills teaching and management of risk. The registered manager must ensure that the homes keyworker system is fully implemented and that staff are fully trained regarding these responsibilities The manager designate must ensure that further work is done Timescale for action 30/09/05 2. YA2.1 5.2 30/11/05 3. YA 6 15.1 and 2 30/11/05 4. YA 6 18 (a) 31/10/05 5. YA 8 16 (2)(n) 31/10/05 Page 24 Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 6. YA 24 23.2(a) 7. YA 32 18.1 (c) 8. YA 33 18 .1 (a) 9. 10. YA 37 YA 39 9(2)(b.1) 24.1 and evidence provided to ensure that service users are offered opportunities to participate in the day-to-day running of the home. (Previous timescale 31/03/05 not met The registered provider must submit details to the CSCI on how it intends to meet the requirements of the Disability Discrimination Act 1993, Part 3. (Previous timescale 31/03/05 not met.) Failure to meet this requirement may result in enforcement action The registered manager must ensure that 50 of the care staff achieve the NVQ 2 award in care and that this level is maintained regardless of numbers of service users present in the home The registered manager must specifically define minimum staffing levels for the home to ensure that staff numbers and skill mix effectively meet service users needs The registered manager must achieve NVQ level 4 in management and care The manager designate must ensure that appropriate quality assurance tools are investigated and implemented to allow the home to assess and improve its own service comprehensively. Previous timescale of 02/01/05 unmet 30/10/05 31/12/05 30/09/05 28/02/06 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 25 Holmbury Dene 1. YA14 The registered manager should explore means of improving the system for planning weekly and daily activities with service users and for monitoring outcomes Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection 46 Loman Street London SE1 0EH 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 Holmbury Dene G52-G02 S25625 HolmburyDene V222118 290405 stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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