Inspection on 06/10/06 for Humphry Repton House

This inspection was carried out on 6th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Humphry Repton House 17/12/08

Humphry Repton House 22/11/07

Humphry Repton House 01/11/05

Humphry Repton House 28/04/05

Humphry Repton House 19/10/04

Humphry Repton House 06/04/04

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

CARE HOMES FOR OLDER PEOPLEHumphrey Repton HouseBrentry Lane Bristol BS10 6NALead InspectorVanessa Carter Key Unannounced Inspection 6th October 2006 09:00X10015.docVersion 1.40Page 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 organisationReader InformationDocument 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.ukInternet addressHumphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 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 Older People. 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.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 3 SERVICE INFORMATIONName of service Humphrey Repton HouseAddressBrentry Lane Bristol BS10 6NATelephone 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)0117 9592255 0117 9709301admin@aspectsandmilestones.org.uk Aspects and Milestones TrustMrs Deborah Jane Stone Care Home 44Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (42) of placesHumphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 4 SERVICE INFORMATIONConditions of registration: 1. 2. 3. 4. May accommodate up to 10 persons aged 50 years and over with dementia Manager must be a RN3 or RNMH on the NMC register The two additional respite rooms must not be used until a follow up visit by a CSCI Inspector has been made May accommodate one person aged 46 at the time of registrationDate of last inspection1st November 2005Brief Description of the Service:SUMMARYThis is an overview of what the inspector found during the inspection. This unannounced key inspection took place over 8 ½ hours on one day. Evidence has also been obtained from a number of other sources, namely: Pre-Inspection Information supplied by the Home Manager Information supplied by relatives in survey forms Information that has been received by CSCI since the last inspection Touring the home Talking to the home manager and the deputy manager Talking to staff Observations of residents and their interaction with other residents and the staff team Looking at staff and care records Looking at other documentation and policies of the home The overall analysis is that the home is an adequate place in which to live and to work. Improvements in a number of areas would ensure that residents safety is further protected.What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 7 DETAILS OF INSPECTOR FINDINGSCONTENTSChoice of Home (Standards 1­6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the InspectionHumphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 8 Choice of HomeThe intended outcomes for Standards 1 ­ 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home.The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT ­ we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good information to prospective residents to enable them and their families to make an informed choice about the home and what it has to offer. The pre-admission assessment processes ensure that placement is only offered to those whose needs can be met. EVIDENCE: The Statement of Purpose and Service Users Guide (home brochure) has been updated since the last inspection to reflect the changes in the environment and the facilities available. Any prospective resident is provided with a copy of the homes brochure. Copies will also be displayed in the main reception once the refurbishment of this area has been completed. Each new resident is provided with a Licence Agreement or a statement of terms and conditions. This sets out the terms and conditions of occupancy and the fees payable.Humphrey Repton House DS0000020250.V313699.R01.S.doc Version 5.2 Page 9 The home has robust pre-admission assessment processes and the documentation completed for one of the recently admitted residents was examined. The assessment tool is a comprehensive document and provides a clear picture of the residents specific needs. When local authorities are involved in the arrangements for placement, a care plan and health needs assessment is obtained as part of the information gathering process. The homes admission process ensures that placement is only offered to those people whose needs they can meet. One social worker team manager responded on a CSCI comment card that the home provided the specialist service that their person had required. The home is registered to provide placement for people with dementia, who may also have challenging behaviour. The staff team are appropriately skilled to care for this client group. Most residents are also frail and elderly, and therefore can also have a range of other physical disabilities.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 10 Health and Personal CareThe intended outcomes for Standards 7 ­ 11 are: 7. 8. 9. 10. 11. The service users health, personal and social care needs are set out in an individual plan of care. Service users health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the homes policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect.The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT ­ we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes care planning processes ensure that each resident is cared for as an individual and their health and personal care needs will be met. EVIDENCE: Care planning documentation for six residents were looked at, two just to check on specific information. Detailed plans have been prepared for each resident. Where residents have been admitted after a hospital admission, an in-depth assessment of the residents specific needs and behavioural traits, is provided by the nursing staff. These included a section of successful interaction that has elicited positive responses ­ this useful information had been incorporated into the plan of care.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 11 The home plans each residents care based upon a person-centred assessment and their needs are recorded in the form of things I need help with. They cover all aspects of health, personal care, cognitive abilities and difficulties, personality and social care needs. The plans are written in collaboration with residents family or representatives. The plans are re-evaluated and amended on a monthly basis. In each file there is an overall summary of care needs and this provides a quick guide to specific needs. One persons `handling aggression plan needed updating as they had now settled in to the home. Another persons plan needed greater detail in respect of their physical health needs and how any deterioration might present to the care staff. The records of two residents showed that they had had a marked weight loss, but it was not clear to see what action had been taken as a result of this. Observation during the mealtime and a discussion with the manager at the end of the inspection clarified the actions being taken, but the records must show the strategies in place to maintain a residents weight. The homes GP completed a CSCI survey form and stated that they were satisfied with the overall care provided to residents within the home. The plans are supported by a number of risk assessments, including waterlow assessments that measure the risk of developing pressure sores, and a manual handling assessment. Whilst the moving and handling profile details the support a resident needs in respects of different transfer movements, (bed to chair, chair into bath for example) each are recorded separately. It would be good practice for the home to develop a Safe Systems of Work form, detailing equipment needs and those tasks the resident does not require any help with. The quality of wound care planning documentation has improved. The plan included details of how often dressings were to be renewed, and what products are used, so that care staff are aware of the actions they need to take. Daily notes were detailed and provided a record of care given and any other events that have occurred. In some places the use of terminology was inappropriate. For example one persons plan stated they preferred to sleep on the sofa, but their daily notes recorded refused to go to bed. The home has sound procedures in place for the ordering, receipt, storage, administration and disposal of medications. The home does not store any more than one months supply of medications. Due to the specific needs of many of the residents, their medications are crushed and added to jam but residents are always advised they are receiving their medications. This procedure is used to ease administration rather than as a means to hide medicines. The use of sedation is kept to a minimum, only being used as a last resort after diversion and distraction tactics have been tried. Examination of the medication administration sheets evidenced this.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 12 During the inspection, staff were observed interacting with the residents in a friendly and appropriate manner. The staff were attentive and responding to the residents sensitively. Discussion with some staff evidenced that they had extensive knowledge about the residents and their specific likes and dislikes. Personal care was given with respect to dignity and privacy, and bedroom doors are fitted with privacy locks. However, the practice of displaying personal information about residents, or pictures of a hoist to remind staff of manual handling procedures, on the outside of their bedroom doors is institutional and is poor practice. Personal information was removed during the inspection, and it is expected that the pictures of hoists will be promptly removed. The home continues to provide placement for residents who are dying, and have produced a well thought out booklet for relatives that may help them with the grieving process. The manager referred to one such resident who had recently died, and how they met specific wishes that had previously been discussed. One member of staff said they had recently done some training in end of life/terminal care.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 13 Daily Life and Social ActivitiesThe intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them.The Commission considers all of the above 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, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to participate in a range of meaningful activities and are provided with a well balanced diet. EVIDENCE: The home has two activity organisers, one full time and one part time. On a daily basis, a number of different activities are arranged ­ on the day of inspection, some residents took part in a reminiscence session and were singing whilst other were talking about the daily newspaper and magazines. There is a range of activities and some are provided by outside entertainers. Activities include music sessions, pets as therapy, exercise groups and films. The staff will provide the necessary support to enable any resident to continue with any other activities and arrangements outside of the home. The day care centre has now moved into its own premises, and this means that the entrance hall is now always available for the residents use. A number of residents were seen taking exercise, and walking around either in the courtyard, or in the home. During the course of the inspection, a trainee vicar visited the home and spent time talking to residents.Humphrey Repton House DS0000020250.V313699.R01.S.doc Version 5.2 Page 14 Residents have daily care plans and can get up or go to bed when they wish. They are also able to move independently around the home as they are able. Residents can choose where they want to sit and where they take their meals The midday meal looked acceptable. There was a choice of fishcakes or beef stew with mashed potato and mixed vegetables, followed by stewed rhubarb. Each resident is offered a visual choice at each mealtime. Alternative meals and puddings were provided when residents expressed a dislike. A number of residents were assisted to eat their meals whilst others were encouraged to help themselves. The mealtime was unhurried and there was good interaction noted between staff and residents. This evidenced that residents are cared for as individuals and is good practice. One relative had previously complained that loud and inappropriate pop music is played during mealtimes ­ the manager has ceased this practice. Background, classical music was playing on one unit.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 15 Complaints and ProtectionThe intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users legal rights are protected. Service users are protected from abuse.The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT ­ we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be assured that any concerns they have will be listened to and acted upon. Improvements in staff awareness of safeguarding adult issues would ensure that residents are protected from any potential harm. EVIDENCE: The homes complaints procedure is included in the homes brochure and will be displayed in the main reception area once this has been refurbished. Since the last inspection the home have dealt with four complaints and the manager explained the actions taken so far, to try and bring about a resolution to the complaints. These complaints have resulted from the building works and been made by members of the public who live opposite the home. One further complaint was made directly to CSCI. This was from a relative who had been concerned about some aspects of the care of their family member and an explanation provided by the home to an incident that had occurred. The complaint was handled under safe guarding adults protocols, in addition the home were advised to look at a number of staff practices. The outcome has not yet been finalised.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 16 The homes policy on the protection of vulnerable adults (POVA) was last reviewed in June 2005 and should be looked at to ensure that it remains up to date. Copies of the current Bristol City Council No Secrets Guidance are available for the staff. The home arranges abuse awareness training for the staff team, and plans several sessions throughout the year. Staff spoken to during the course of the inspection, provided appropriate responses when questioned about `serious abuse matters and were fully aware of their responsibilities in protecting residents from any form of harm. However, there is concern that the staff team may not act appropriately to safe guard residents when a resident who has challenging behaviour, is either subjected to physical assault or is the instigator of such. The manager has agreed to make contact with the local authority Safe Guarding Adults Officer for clarification on how the home should deal with incidences of repeated aggression between residents.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 17 EnvironmentThe intended outcomes for Standards 19 ­ 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic.The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT ­ we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable and safe but the improvements that are in progress, will mean that all residents will benefit from living in a home that looks nice. EVIDENCE: Humphrey Repton House is a purpose built care home that has benefited from recently being extended, to provide additional resources and more beds. The home is now able to accommodate up to 44 residents, two of the beds being available for short-term placements, whilst the other 42 are for permanent placement. On site there is also a self-contained day care centre and offices for the domiciliary care services ­ these facilities have now moved out of the home and therefore enhanced the home environment by providing more space for the residents and the home staff. The home is surrounded by pleasant gardens that are secure and are designed with sensory stimulation in mind.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 18 The main entrance into the home has yet to be completed, but the manager explained that this will contain comfortable seating, the visitors signing in book, a display of information and photographs of the staff team. Once finished the main front door will be secure and the doorbell will be programmed into the deck-phones carried by the qualified staff. The home is arranged as four wings, three being in the original part of the home and the forth being in the new build. Each area has its own communal areas, assisted bathrooms and toilets. The three wings are situated around a central courtyard, each containing ten bedrooms. All bedrooms have a wash hand basin and doors, leading out on to the garden area. A number of the bedrooms have already been redecorated and there will be a rolling programme to complete the works in the remaining rooms. The communal areas are currently in the process of being refurbished and redecorated. The flooring is to be replaced throughout, and new doors fitted between each wing and the bedroom areas. The overall end result will be that the same decorative scheme will be followed throughout the whole home. The two new short stay rooms are situated in this part of the home. The forth wing is in the new building. Each of the 12 bedrooms has ensuite facilities of a wash hand basin and toilet, and they are furnished with specialist nursing beds. The new laundry room is equipped with two large washing machines and one tumble dryer, and all personal and home laundry is attended to in-house. The new kitchen is fully equipped. Both facilities are located in the link corridor between the two areas of the home. The home was generally clean and tidy, despite the fact that workmen are in the home, and there was a certain amount of mess being made by them. The housekeeping staff were seen working diligently, and making every effort to keep the home looking nice. There were no unpleasant odours.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 19 StaffingThe intended outcomes for Standards 27 ­ 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the homes recruitment policy and practices. Staff are trained and competent to do their jobs.The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT ­ we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The establishment of a stable staff team would ensure that residents are cared for by staff who are familiar with their care needs. EVIDENCE: Since the last inspection there has been a high staff turnover - unfortunately occurring at the same time as the home increased the number of residents. There are currently nine staff vacancies and therefore there has been a large amount of agency staff use. The information provided by the manager in the pre-inspection information, showed that a vast range of different workers covered shifts. However, since this time the home has negotiated a contract with an agency and in the main, just four workers will be used. The home has ongoing recruitment procedures in place. The CSCI survey form received many comments from relatives about the use of agency staff ­ concern being expressed that their relatives are being cared for by staff who are not familiar with their needs. The manager is fully aware of these concerns and is taking active steps to resolve the staffing shortage. One relative commented on the CSCI survey form that the staff and care at Humphrey Repton is fantastic. I cant praise them enough. The home has 13 qualified members of staff, 30 support workers and eight ancillary workers. The home prides itself on providing a multi-racial staffHumphrey Repton House DS0000020250.V313699.R01.S.doc Version 5.2 Page 20 team, with staff from European, African and Asian countries. Of the support staff, six or 20 have already achieved at least a level 2 National Vocational Qualification in Care. Ten further staff are at various stages in completing the award (53 ) plus some of the qualified staff are completing the A1 Assessor award. The home must continue to work towards the minimum ratio of 50 trained members of support staff to ensure that skilled and competent staff, care for the residents. The staff files of newly recruited staff members were examined. Whilst the home had obtained two written references from previous employers for each employee, and had received CRB disclosures, there was no evidence that the worker was not included on the POVAlist, prior to their employment commencing. The manager has subsequently advised CSCI that some of the workers had started work in the home before confirmation that they had not been barred from care work. This is unacceptable and does not comply with safe vetting procedures. All new staff complete an induction training programme at the start of their employment, to ensure that they are aware of the homes procedures and are competent in all areas of their work. One staff member said they had been allocated a mentor to help them settle in to the job. The home ensures that the staff team have the appropriate skills to care for the residents. The training plan for 2006 includes manual handling, food hygiene, fire, first aid and abuse awareness, as statutory updates for the team. There has also been health & safety awareness, racial awareness and wound care management. Future training includes further dementia care training, assertiveness training and managing difficult people.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 21 Management and AdministrationThe intended outcomes for Standards 31 ­ 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users financial interests are safeguarded. Staff are appropriately supervised. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT ­ we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, and residents benefit from a safe and secure environment. EVIDENCE: The Home Manager has been in post for three years and is a registered nurse in mental health. The manager continues to play a very active role in the development of the new premises and the increased number of permanent and respite beds.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 22 A deputy manager, also a registered nurse, supports the Home Manager in the running of the home, along with three lead nurses, a team of registered nurses and care staff. The senior managers (home manager and deputy manager) work together during the week and provide on-call cover arrangements for the weekend and `out of hours. Staff team meetings are held on a monthly basis and one was planned for the day of the inspection. During the meeting, operational matters were discussed along with a conversation about racial awareness. The manager will also hold qualified staff meetings on a regular basis. Support groups for relatives are held on a once a month basis. These have just recommenced following a break whilst the building works were going on. The manager explained that now that the building works have been completed, the Trust will organise an annual review, to include the opinions and views of residents (where possible), relatives, staff and any other stakeholders. The outcome of this survey will form the basis of the homes development and future inspections by CSCI. A senior manager from Aspects & Milestones completes quality assurance monitoring visits, each month. The home looks after small amounts of personal monies for a number of residents, and records are kept of transactions in and out of the accounts. The manager completes regular audits of the home in respect of health and safety. The Environmental Health Officer has recently inspected the kitchen and food hygiene arrangements. The fire records were examined. All the necessary weekly, monthly and quarterly checks had been completed. All staff have received recent fire training. Risk assessments are carried out for all safe working practices and records are maintained when any restrictive measures need to be taken to secure a residents safety. As previously referred to, the home completes moving and handling assessments but the documents are cumbersome to trawl through. It would be good practice for a `safe system of work to be devised following the assessment, so that staff have a clear easily understood document to refer to, and the need to display pictures of hoists on bedroom doors is removed.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 23 SCORING OF OUTCOMESThis page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 applicableCHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 263 3 3 3 3 N/AHEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 23 3 3 3 3 3 3 3STAFFING Standard No Score 27 2 28 3 29 1 30 3MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score3 3 3 X 3 X X 3Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 24 Are there any outstanding requirements from the last inspection?NoSTATUTORY 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 OP7 Regulation 15 Requirement Timescale for action 06/11/062.OP1813(6)3.OP2919 Schedule2Care plans must always be updated to reflect any changes in need, and must provide staff with clear guidance on what actions are necessary to meet identified need. The home to have protocols in 06/12/06 place to deal with, and manage, potentially abusive interpersonal relationships between residents. Information to be incorporated in individuals care plans. Safe vetting and recruitment 01/11/06 procedures must include POVAfirst clearance being obtained before a worker starts their employment. Evidence of this must be retained in the home.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP18 OP28 OP38 Good Practice Recommendations The homes policy on adult abuse to be reviewed, taking in to consideration the requirement notice issued with this report. The home should achieve the ratio of 50 trained members of staff (at NVQ Level 2) by the end of 2006. The home should devise a `Safe System of Work following on from the moving and handling profile, so that staff have clear, easy to understand guidance.Humphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 CSCIHumphrey Repton HouseDS0000020250.V313699.R01.S.docVersion 5.2Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!