Inspection on 10/08/07 for Homeleigh

This inspection was carried out on 10th August 2007.

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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Homeleigh 23/07/08

Homeleigh 30/08/06

Homeleigh 04/10/05

Homeleigh 07/06/05

Homeleigh 04/11/04

Homeleigh 24/06/04

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

CARE HOME ADULTS 18-65 Homeleigh Sondes Road Deal Kent CT14 7BW Lead Inspector Joseph Harris Key Unannounced Inspection 10th August 2007 10:00 Homeleigh DS0000023280.V345353.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 Homeleigh DS0000023280.V345353.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. Homeleigh DS0000023280.V345353.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Homeleigh Address Sondes Road Deal Kent CT14 7BW 01304 380040 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) Homeleigh Care Ltd Mr Dhunputh Seewooruttun Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Homeleigh DS0000023280.V345353.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 4 residents with learning disabilities must also have mental health difficulty 30th August 2006 Date of last inspection Brief Description of the Service: Homeleigh is a residential home for people with enduring mental health problems situated in the seaside town of Deal. The home is registered for up to 16 people between the ages of 18-65. The service is set out over two floors, with a small number of bedrooms on the ground floor and the remainder on the first floor. The home benefits from a good level of communal space with a large lounge and an ample dining room. There is also a designated smoking room. A secure courtyard garden is located to the rear of the building. There are adequate kitchen and laundry facilities. The service has a relatively small, but stable staff team, many of whom have worked in the home for a number of years. The house is located very close to Deal town centre and within view of the sea. There are relatively good public transport links nearby and the town is well equipped with public facilities such as a library, cafes, sport centre, cinema and theatre. The current fees for the service at the time of the visit range from £335.00 to £475.00 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. Homeleigh DS0000023280.V345353.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection process culminated in a site visit to the home on 10th August 2007. During the course of the visit a tour of the premises was undertaken and discussions were held with the registered manager, staff members and service users. A range of documentation was examined relating to the residents, staff, medication, health and safety and the day-to-day running of the home. The home also returned the Annual Quality Assurance Assessment (AQAA), which provides information to inform the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Homeleigh DS0000023280.V345353.R01.S.doc Version 5.2 Page 6 6 requirements and 10 recommendations have been made as a result of this inspection. A number of these issues, it is acknowledged, are attributed to ongoing development as outlined in ‘What has improved since the last inspection’. Among the requirements is the need to develop a more robust risk assessment process balancing responsible risk with the protection of service users. The home needs to ensure that all staff training requirements are up to date and look to expand training in respect of medication and mental health awareness as well as mandatory topics. Additionally the Registered Manager needs to complete his NVQ 4/RMA. The home needs to enable service users to have freedom of access in and out of the home and within the home providing keys unless otherwise assessed. 1 staff recruitment file was noted to have a number of omissions, which also needs to be addressed. Amongst the recommendations are issues to continue to develop care planning, activities and support service users towards a more independent lifestyle. There is quite a sedentary lifestyle and the staff in the home could be more proactive in supporting service users towards this end. The home needs to ensure that fire escapes, in particular the front door, can be easily opened from the inside in the event of fire. Some limitations are in place for a number of service users, which need to be clearly assessed and agreed within the multi-disciplinary team. Contracts, healthcare records and the staff rota also require updating. 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. Homeleigh DS0000023280.V345353.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 Homeleigh DS0000023280.V345353.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): 2 and 5. Quality in this outcome area is adequate. Prospective service user’s needs are assessed and they are provided with satisfactory information about the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home ensures that information is provided from care managers through the Care Programme Approach (CPA) regarding new and prospective service users. This information details the most recent care plan and risk assessment. In addition to this the home complete their own pre-admission assessment following a visit to see the prospective resident and trial visits to the home. The pre-admission assessment covers all areas of need although attention should be paid to the detailed assessment of the mental health needs of the individual and any potential restrictions that are to be imposed. A contract covering the statement of terms and conditions is provided, however old contracts from the previous ownership had not been updated and, in some cases, a copy of the contract had not been retained on file. It is advised that all service users are issued with the company’s most up-to-date contract. These should be signed by the individual and/or representative where Homeleigh DS0000023280.V345353.R01.S.doc Version 5.2 Page 9 capacity issues are present and a signed copy retained on file for all service users. Refer to recommendation 1. Homeleigh DS0000023280.V345353.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): 6, 7 and 9. Quality in this outcome area is adequate. Individual plans of care and risk assessments are developed for each service user that could benefit from further detail. Residents are able to make decisions about their lives, but restrictions and limitations to daily life need to be clearly identified. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three service user files were viewed during the course of the visit. The home has continued to develop service user plans and a simple, but effective format for detail care and support needs has been developed. Amongst the files viewed the care plans had been developed relatively well addressing a range of care needs. However, these focussed on practical issues such as personal support and physical healthcare needs. The home needs to place a much greater emphasis on the rehabilitation of residents, social needs and mental Homeleigh DS0000023280.V345353.R01.S.doc Version 5.2 Page 11 health needs. This is particularly relevant where service users are working on daily living skills to improve their level of independence. Refer to recommendation 1. Additionally, more clarity could be brought to the action aspect of the care plans ensuring that staff are provided with clear guidance on how to meet and address individual needs consistently. Service users stated that they feel free to come and go from the home as they please and are able to make decisions about their day-to-day lives. However, a number of restrictions are in place for some of the residents ranging from handing in their lighters, to leaving the home unsupervised. These restrictions are not always clearly documented with the individual plans of care and evidence needs to be shown that these limitations have been discussed with the service user and healthcare team. Refer to recommendation 3. It was reported that the home/organisation is no longer appointee for any of the current residents and that finances are paid into a central account for service users separate to the business account. The vast majority of residents have their finances managed through care management and by families. All residents spoken with confirmed that they receive their personal allowance weekly. Records were examined for 3 service users, which demonstrated that allowances are given weekly and all income and outgoings are appropriately documented with attached receipts. It was reported that the finances of each resident are regularly audited by the organisation. The home has also begun to develop risk assessments and management plans for each resident. Through a case tracking exercise a number of shortfalls were identified in the risk management process. For one service user, who is relatively new to the home, pre-admission information highlighted a number of risk areas such as going out alone, fire and recognising hot temperatures however these issues had not been addressed through risk assessments. This was also apparent amongst other service user files examined. Refer to requirement 1. Homeleigh DS0000023280.V345353.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): 11, 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. Service users have a relaxed lifestyle, but could be supported to extend their opportunities. A healthy and balanced diet is provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home offers relatively few opportunities and support to assist residents in their personal development and independent living skills. Through discussion with residents and staff it is evident that some support is provided in these areas, but this is generally not structured support with no long and short term planning in place. The home staff and management could take a more proactive role in supporting residents with daily living skills such as cooking, budgeting, using public transport and other skills. Additionally there are a number of local mental health resources in the local and surrounding areas, Homeleigh DS0000023280.V345353.R01.S.doc Version 5.2 Page 13 but at the present time none of these are accessed by any of the service users, which is also an area to be explored. Refer to recommendation 4. The home is starting to improve the range of activities in the home, although this remains an area of development. An activities folder is maintained and events have been arranged such as a Barbeque and music night, trips out and a visiting entertainer. However throughout the inspection visit residents had little to occupy themselves and no activities on a group or individual basis were organised. Residents made comments such as, “It’s boring, there’s nothing to do. I’d like to go to the pub” and “There’s not much to do, but I’m not feeling well so I don’t want to do much”. Some residents like to go out alone and do not wish to participate in group activities, but from the records available it was clear that there is a core group of 6 residents who regularly engage in organised activities. The home needs to take a more positive and encouraging role in daily leisure pursuits suiting the individual needs of all residents. Refer to recommendation 5. Residents and staff reported that visitors are welcomed into the home at all reasonable times and the home liaises appropriately with families and next of kin. There were no opportunities to speak to visit during the course of the site visit. One resident said, “My kid sister likes to visit me most weeks”. The home has well organised daily routines, sometimes, in the opinion of the inspector, which are too rigid and lacking flexibility. There is a balance to be struck between the need for structure in the day and providing a stimulating and varied lifestyle. All bedrooms are lockable and some service users do not have keys to their rooms relying on staff to open the doors for them. Similarly residents do not have keys to the front door. This is an area that needs to be re-examined. It was reported that some residents were not assessed as able to care for keys or others would wander into their rooms. Such issues need to be clearly documented and discussed with the care management team. Where possible residents should be able to access their bedrooms at all times and have access in and out of the home as they wish. Refer to requirement 2. All residents reported that they get good food and a balanced and varied diet wit a range of choices. Menu records supported this and the home’s food stores were well stocked with good quality food. Meals are taken in a good-sized dining room and are relaxed and comfortable times of the day. Nutritional needs and special dietary requirements are catered for. Homeleigh DS0000023280.V345353.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): 18, 19 and 20. Quality in this outcome area is adequate. Service user’s personal and health care needs are met and medication in the home is appropriately managed, however record keeping needs improving. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Most of the service users require only encouragement and minimal levels of support in assisting with personal care. Individuals who require more assistance are supported by staff in a dignified manner ensuring privacy. Guidelines and preferences relating to personal support are documented and regularly reviewed. Aspects of daily life such as choosing when to get up and go to bed are left to personal choice unless an assessed need is identified. Any specialist support required is provided in conjunction with the relevant healthcare professionals including support from the local community mental health services. The healthcare needs of service users are appropriately managed, although some attention could be given to the recording of healthcare issues ensuring Homeleigh DS0000023280.V345353.R01.S.doc Version 5.2 Page 15 that there is a clear flow through of information from identifying an issue to referral to an appropriate practitioner to the outcomes of any consultation. The home also needs to ensure that records are maintained of visits to all healthcare professionals and that residents are offered the chance to see complimentary healthcare professionals such as chiropodists, dentists and opticians. Refer to recommendation 6. It was reported that the home receives good support from the local community mental health team. The medication is managed well within the home. There are adequate policies and procedures and storage facilities in place. The home’s administration records are clear, well maintained and up to date. None of the service users are assessed as able to self-medicate, which is an aspect of care that could begin to be expanded with appropriate assessment and liaison. There is adequate provision for the use and storage of controlled drugs. Staff who administer medication are provided with basic training in this respect, but more detailed medication training is now widely available, which needs to be provided to staff. Refer to requirement 3. The home should also consider introducing competency assessments for staff regarding medication issues. Homeleigh DS0000023280.V345353.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): 22 and 23. Quality in this outcome area is adequate. Service users are able to make complaints and air their views appropriately. The home has processes in place to protect service users from forms of abuse, however there are some gaps in the recruitment process that could put them at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure in place, which is displayed and accessible to all. The home aims to deal with any concerns or complaints on an informal basis in the first instance, but formal processes would be followed should this prove unsatisfactory. There are regular resident meetings enabling service users to air their views/concerns. Minutes are taken at these meetings and issues and action revisited at subsequent meetings. Staff and management are approachable and demonstrated good interpersonal skills when talking to residents. It was reported that there have been no complaints since the last inspection. The home has now introduced improved policies and procedures regarding the protection of service users from abuse and staff have completed adult protection training. In discussion staff were able to state appropriately what actions they should take if they suspected any form of abuse and other aspects of underpinning knowledge were evident in this regard. It was reported that no adult protection alerts have been raised since the last inspection. Homeleigh DS0000023280.V345353.R01.S.doc Version 5.2 Page 17 Homeleigh DS0000023280.V345353.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): 24 and 30. Quality in this outcome area is adequate. The home is fit for purpose and suitable for the needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises revealed that the home is suitable for the individual and collective needs of the service users. There are a number of communal spaces including a good-sized lounge and a dining room. The home has a room, which was used as a smoking room, but that is now going to be converted into a games room. Service users now have a covered area outside in which to smoke due to the new legislation. All communal rooms are adequately furnished and are bright, airy and comfortable. There is a paved area to the rear of the home, which is being developed to provide residents with a small area for gardening. Attention should be given to the step from the games room to the garden, which is a potential tripping hazard for residents with reduced Homeleigh DS0000023280.V345353.R01.S.doc Version 5.2 Page 19 mobility. The home also needs to attend to the security of the front door, which has multiple dead bolt locks and a keypad system. This represents a potential fire hazard and suitable security needs to be in place, which allows quick egress in the event of a fire. There are two double bedrooms in the home. Residents who share stated that they are happy to do so, but in future express consent needs to be given to share a room. Residents currently sharing should also be offered single rooms when available. One double room needs suitable screening to be provided to ensure privacy. Refer to recommendation 7. During the visit the home was seen to be clean and hygienic throughout. Laundry facilities are suitable for the needs of the home and meet all relevant specifications. Hazardous substances (COSHH) were safely and securely stored. There are adequate policies and procedures in place to ensure the control of infection and universal precautions. A recent environmental health visit commended the cleanliness of the kitchen in the home and gave no requirements. Homeleigh DS0000023280.V345353.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): 32, 34 and 35. Quality in this outcome area is adequate. There is a competent staff team in place, although training requirements need updating. The home needs to ensure that recruitment checks are adequately followed through. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home management and organisation have worked well to support staff to obtain National Vocational Qualifications and, with the exception of recently appointed staff; all team members have achieved at least an NVQ level2 with the Deputy Manager considering taking an NVQ level 3. Most staff have worked at the home for an extended period of time, but recently 3 new staff have been employed. One stated that she has had a detailed induction process and additional training since starting work in the home. Some minor adjustments need to be made to the staff rota, which is based on a 4-week rolling rota. However the dates of each week have not been entered; staff designation and roles are not included and the rota has not been updated to show sickness and arrangements for cover. Refer to recommendation 8. Homeleigh DS0000023280.V345353.R01.S.doc Version 5.2 Page 21 3 staff personnel files were examined, 2 of which contained all required information. However, one file lacked the required information and raised questions regarding the recruitment process. 1 reference gained had been from the staff member’s spouse, additionally there was no current CRB or POVA check in place. A CRB form was on file from a previous employer. However, this employer had not been included on the staff member’s CV or application form raising a concern about the employment history. A two year gap was also evident in the individual’s employment history, which needs to be explored by the management of the home. Refer to requirement 4. There was some ambiguity surrounding staff training in the home. The Common Induction Standards have been introduced and staff work through a measured competency based induction process. However, the staff training matrix only showed recent training provided, most of which is in-house training. It was reported that the Quality Assurance manager is a trained trainer in a number of mandatory topics and an NVQ assessor, but evidence was not available of these qualifications. According the training matrix a number of foundation training areas require attention such as food hygiene, detailed fire training and first aid for some staff. The home needs to ensure that clear evidence is available that all training needs are being met. Refer to requirement 5. Homeleigh DS0000023280.V345353.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): 37, 39 and 42. Quality in this outcome area is adequate. The home is well managed, although the manager needs to obtain the appropriate qualifications. Quality assurance processes are being developed and the health, safety and welfare of service users is protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has extensive experience in the care sector having qualified as a psychiatric nurse many years ago. However, his qualification has now lapsed. He has worked in the home as manager for around 15 years. He still needs to complete his NVQ 4/RMA, which he has been working towards for a few years. Refer to requirement 6. Homeleigh DS0000023280.V345353.R01.S.doc Version 5.2 Page 23 The organisation has appointed a quality assurance manager who is responsible for monthly monitoring visits and auditing records. He has begun to develop quality monitoring processes having introduced service user questionnaires and regular monitoring visits. However, this processes needs to continue to be expanded. This could include satisfaction questionnaires for all stakeholders including staff, professionals and relatives/visitors. On receipt of completed surveys the information should be collated into a quality report providing details of responses and putting action plans in place to address any identified service weaknesses. Refer to recommendation 9. All health and safety information and documentation was in place and up to date including service certificates and policies and procedures detailing safe working practices. Environmental risk assessments are completed and accident records maintained. Fire records were also up to date, although the home needs to ensure that fire drill records are appropriately maintained with evidence of which staff have participated in drills. Refer to recommendation 10. Homeleigh DS0000023280.V345353.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 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 2 12 2 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 3 X Homeleigh DS0000023280.V345353.R01.S.doc Version 5.2 Page 25 No 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 YA9 Regulation 13(4) Requirement To ensure that all risks are clearly identified using the information available and knowledge of the individual. To ensure that risk assessments provide clear actions to minimise the perceived risks. To ensure service users have keys to the front door of the home and their bedrooms unless otherwise assessed by the multidisciplinary team. To ensure staff are provided with sufficiently detailed and competency based formal medication training. To ensure all staff recruitment files have all required information, gaps in employment history are explored and CRB/POVA checks are gained prior to unsupervised working. To provide evidence that all staff training needs are being met and to ensure all mandatory training is updated as required. The registered manager to achieve an NVQ 4/ Registered Managers Award. Timescale for action 01/10/07 2. YA16 12(4)(a) 01/10/07 3. YA20 18(1)(c) 01/11/07 4. YA23 YA34 19, schedule 2 01/10/07 5. YA35 18(1)(c) 01/10/07 6. YA37 9 01/12/07 Homeleigh DS0000023280.V345353.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. Refer to Standard YA5 YA6 YA7 Good Practice Recommendations To ensure all service users are provided with an up-to-date contract covering the terms and conditions of residency and a signed copy retained on file. To continue to develop service user plans with a focus on rehabilitation, mental health needs and clear actions to meet needs. To ensure that all restrictions and limitations in respect of service users are clearly documented and evidence of liaison with the service users and healthcare team is available. To support service users to develop activities of daily living in a planned and consistent manner. To continue to develop the range of individual and group activities available for service users. To ensure healthcare records clearly reflect the outcomes of any consultations and that residents have regular access to complimentary health care professionals as required. To ensure easy egress from the front door in the event of fire. To ensure adequate screening is available in all shared bedrooms. To ensure that the staff rota provides an accurate reflection of the staff on duty. To continue to develop quality monitoring processes. To ensure a record of fire drills is appropriately maintained. 4. 5. 6. 7. YA11 YA12 YA19 YA24 8. 9. 10. YA33 YA39 YA42 Homeleigh DS0000023280.V345353.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Homeleigh DS0000023280.V345353.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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