CARE HOME ADULTS 18-65
Inglemere 2 Pollards Hill East Norbury London SW16 4UT Lead Inspector
Barry Khabbazi Unannounced Inspection 19th December 2005 9:30 Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 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 Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 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. Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Inglemere Address 2 Pollards Hill East Norbury London SW16 4UT 020 8679 6726 020 8679 6726 NO EMAIL 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) Surrey Oaklands NHS Trust Mrs Melanie Davies Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 31st May 2005 Brief Description of the Service: Inglemere provides residential care for up to nine adults with moderate to severe learning disabilities. Some service users are also visually impaired. Inglemere is owned, managed, and staffed by the Surrey Oaklands Trust, a specialist health provider for people with learning disabilities. Each service user has their own bedroom, which is decorated to suit their individual tastes. The home is situated on a corner plot surrounded by gardens and a patio area. The home has a communal lounge area as well as a dining room. It is within walking distance of Norbury high street and transport links. The home is close to the Croydon /Merton boundary Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection focused on observing breakfast and supervision of the service users in the morning, and following up on previous requirements. All the residents were met during this inspection. The key Standards identified throughout this report were all inspected at the last inspection. Please see that announced inspection report for a full audit of all the key Standards. Although it was possible to follow up the implementation of a number of previous requirements, it is recognised that the manager was not present to evidence other requirements that may have also been met. See below for details. What the service does well: What has improved since the last inspection?
The last report recorded that there had not been a registered manager for some time and the person previously covering the registered manager’s post has now left. Since that time a new permanent manager has been appointed. There is now a person responsible for meeting requirements and standards. Although minor shortfalls still exist, the care plans have been re-written in a new format to include a more holistic plan of care. Although minor shortfalls still exist, there are more risk assessments which also are more comprehensive. Service users’ views have been sought, although these still need to be included in the service users guide to inform potential new service users of the current service users’ views of the home. Although daily notes sampled were still not recorded on a daily basis, there had been a marked improvement in frequency of recording daily notes. Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 6 What they could do better:
Although the Statement Of Purpose contains most of the information required it is not yet complete, completing this will help relatives and placing social workers to have a good picture of what the home provides and help them choose between different homes. The service users guide is still not satisfactory as it does not contain the views of the residents and is not available in other more accessible formats. This is important so that new residents can understand their guides and can be clear about how other residents feel about living in this home. {It is accepted that this requirement may have since been implemented but as the manager was not on duty at the time of this inspection, it was not possible to access records to confirm if it had been met.} Although the care plans have been re-written and are much improved, they still do not reflect all of a resident’s needs. This could affect the staffs’ knowledge of the needs of the residents and therefore their ability to meet them. Although some improvement has been made in producing risk assessments, these are still not available for all limitations of liberty and in addition do not contain all the information required, and in particular, details of how training and other options have been explored to avoid the limitations of liberty. Including this information could reduce unnecessary restrictions of liberty for the residents. Although there had been a marked improvement in daily notes, those sampled were still not recorded on a daily basis. Residents do not have sufficient opportunities to be part of the local community and to take part in appropriate activities. {It is accepted that this requirement may have since been implemented but as the manager was not on duty at the time of this inspection, it was not possible to access records to confirm if it had been met.} Residents do not receive all the paid holidays they are entitled to. Addressing this would facilitate more funding, and additional holidays for residents that they do not have to pay for. Although the food provided is sufficient in quantity and is generally sufficiently nutritious, residents are losing weight and are not being sufficiently encouraged to eat healthily . This is important to ensure good health. Although there seemed to have been some improvement since the last inspection, residents do not always receive support in the way they require. Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 7 Restraints Policies and guidance are not readily available to staff, and these policies and guidance are not known by them. This is needed to protect residents whilst being restrained for their own protection and to ensure that restraints only occur as a last resort. Residents rooms do not contain all of the furniture required under Standard 26.2. Unless the resident has made a positive choice not to and this is evidenced in their files, or recorded risk assessments show otherwise, the residents may not be getting all the furniture they are entitled to. {It is accepted that this requirement may have since been implemented but as the manager was not on duty at the time of this inspection, it was not possible to access records to confirm if it had been met.} The home needs to acquire an occupational therapist’s assessment for aids and adaptations to improve access to the general environment and for individual residents. {It is accepted that this requirement may have since been implemented but as the manager was not on duty at the time of this inspection, it was not possible to access records to confirm if it had been met.} Although progress has been made with regards to the home implementing a quality assurance system and an annual development plan, this still needs to be finalised. Without this the involvement of the residents and relatives could be limited. {It is accepted that this requirement may have since been implemented but as the manager was not on duty at the time of this inspection, it was not possible to access records to confirm if it had been met.} Three staff bags, two coats and a jumper were observed on furniture and the floor in the service users’ lounge. Staff do have separate facilities to store their belongings and should not infringe on the service users’ space. The front gate should be repaired to improve ease of use and access for the service users. 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. Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 8 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 Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Although the home provides most of the information needed for potential residents to make an informed decision about moving in to the home, the residents do not have all the information they need. EVIDENCE: The last inspection report contained the following three requirements under Standard 1: 1,The service user guide should be in a format suitable for the service users. 2, The service users guide must contain the views of the service users. 3, The Statement Of Purpose must specify room sizes and both the Statement and the service users guide must contain the qualifications and in particular the relevant experience of the registered provider, manager and staff. The inspector could find no evidence that these requirements had been met. All these 3 requirements were not met at the time of this inspection and remain in force. {It is accepted that this requirement may have since been implemented but as the manager was not on duty at the time of this inspection, it was not possible to access records to confirm if it had been met.} Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, and 9. Although plans of care are now more holistic, all of a resident’s assessed needs, and how the home meets these needs, are not fully recorded. This could affect the home’s ability to meet and show how it has met all a resident’s needs. Although much improvement has been made in producing risk assessments, these do not contain all the information required. Including this information could reduce unnecessary restrictions of liberty for the residents. EVIDENCE: The last inspection report contained a requirement for a record of all of a service user’s needs and how they are to be met and by whom, to be recorded in their plans of care. The care plans have been re-written and are much improved and more holistic. However, the care plans still do not reflect all of a resident’s needs. For example, one file sampled {Resident ‘L’} did not record that he needed support at mealtimes and did not record educational and spiritual needs. This could affect the staffs’ knowledge of the needs of the residents and therefore their ability to meet them. This requirement remains in force.
Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 11 The last inspection report contained the following recommendation: Daily notes should be recorded daily and reflect how the care plan was implemented on that day. Although there had been a marked improvement in daily notes, those sampled were still not recorded on a daily basis. This recommendation remains in force. The last inspection report contained the following requirement under Standard 9: The home must produce risk assessments to evidence how safety outweighs choice where any restrictions of liberty are assessed as necessary for the protection of service users. Although some improvement has been made in producing risk assessments, these are still not available for all limitations of liberty, These could not be produced for example, for the use of the locked kitchen gate. The existing requirement regarding this will remain in force until fully met. The last inspection report contained the following requirement: Risk assessments must contain all the information required under Standard 9.4, and in particular, details of how training and other options have been explored and the involvement of relatives or independent advocates. Although these seem to have been updated on a new pro-forma, these did not cover what training or other options had been offered to the service user to avoid the limitation of liberty concerned. This did however cover staff training. It is possible that the requirement to record training or other options offered to the service users had been confused with staff training. In addition advocacy, relatives or service user involvement was not recorded. The existing requirement regarding this will also remain in force until fully met. Although some improvement has been made in producing risk assessments, these are still not available for all limitations of liberty, for example the use of the locked kitchen gate. The existing requirement regarding this will remain in force until fully met. Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14, and 17. Residents do not have sufficient opportunities to be part of the local community and to take part in appropriate activities. Residents do not receive all the paid holidays they are entitled to. Addressing this would facilitate more funding, and additional holidays for residents that they do not have to pay for. Although the food provided is sufficient in quantity and is generally sufficiently nutritious, some residents are losing weight and are not being sufficiently encouraged to eat healthily. This is important to ensure good health. EVIDENCE: The last inspection report contained the following requirement: The home manager must develop the range of fulfilling activities available to service users in and out of the home. This affects both the activities and community interaction Standards. These are still limited with infrequent evening outings. The expectation would be evening outings during the week and additional outings at weekends. The requirement remains in force untill fully met.
Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 13 {It is accepted that this requirement may have since been implemented but as the manager was not on duty at the time of this inspection, it was not possible to access records to confirm if it had been met.} The last inspection report contained a recommendation for each service user to be offered a seven day holiday. Holidays are still funded by the service users and not the organisation. This has not occurred. The existing recommendation remains in force. The menu at Inglemere is based on a four-week rota, which reflects the likes and dislikes of the residents. The dietician employed by the Trust then checks the menus. Referrals to the dietician are made where required. Alternative meals are provided if the service users do not like the main option. The last report recorded that ‘a number of residents are of low weight and records showed that they are continuing to lose weight. For instance, in one case a drop from a low 43 kg to 40 kg was recorded. Communications with the dietician identified that this was due to the staff not encouraging residents sufficiently to follow dietary plans.’ The following recommendation was set at that time. The home should devise a coherent strategy for balancing a resident’s food choices with appropriate encouragement for nutritional requirements. This strategy should be recorded and its outcome included in daily notes. Daily notes sampled at this visit did not evidence implementing the dieticians dietary plans. The menu also did not, as choices could be as follows in week 1: Tuesday - Lunch-Egg on toast Tea- Meal out. Thursday- Lunch-Tomatoes on toast Tea- Sausages. FridayLunch-Hot Dogs Tea- Fish fingers. FridayLunch-Fish fingers Tea- Pizza. The recommendation remains in force. This area should be examined in detail at the next inspection where a requirement will be set if necessary. Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Residents do not always receive personal support in the way they require. EVIDENCE: On the 26 of April 2005, an early morning additional inspection occurred. The residents were observed to come down into the lounge without any staff supervision or support. A blind resident was seen to be confused and could not find a chair. This resident eventually sat down on a chair that another resident was sitting in. The resident already in the chair became very distressed and attempted to hit the blind resident. The inspector guided the blind resident into a vacant chair before an incident occurred. The following requirement was then set to address this lack of staff personal support and guidance observed: Staff must always provide adequate supervision, support and guidance for the residents. At the time of this inspection, it was again noticed that service users were left to go from breakfast to the lounge unsupervised. It was however noted that the period left alone was shorter than last time. This requirement remains in force. Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 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 the following standard(s): 23 The home’s policies and procedures relevant protection are not all known to staff and therefore do not fully facilitate protecting residents from abuse. EVIDENCE: The last inspection report recorded the following: ‘The organisation has its restraints policy and guidance spread over 3 separate documents. The home was only able to produce one document containing limited restraints guidance called “Responding to Aggression and Violence” policy and procedure. This states that physical restraint should only be used as a last resort and should be recorded to justify the action taken. This did not contain any guidance about what forms of restraint were acceptable and which forms were not acceptable, for example holding clothing instead of flesh to avoid damage to service users. A brief minor unplanned restraint was observed during breakfast, where a member of staff pulled a service user by the arm to the dining table. The following requirement is therefore set: Guidance regarding the use of unplanned restraint and guidance regarding acceptable forms of restraint, and the use of other techniques to avoid restraint must be made available to staff and these procedures must be known by them. Although this guidance has now been produced, only the deputy manager had signed to confirm they had read and understood it. The requirement will therefore remain in force until these procedures are known by staff.’ At this inspection the shift leader could also not find the required policies or the sheet signed to confirm staff had read and understood this. Although the manager may have been able to find these, all staff must be aware and understand these procedures fully. The requirement will therefore remain in force until these procedures are known by staff.
Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 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 the following standard(s): 26, 29, and 30. Although the environment is currently well maintained and suitable furniture is available, residents’ rooms do not contain all the furniture required. This may be because a resident has chosen not to or because of risk. However this must be recorded to ensure that residents have all the furniture they are entitled to. The home does not have all the specialist equipment required to meet all a resident’s needs. The home is hygienic and clean; this environment therefore facilitates the residents’ health and emotional well being. EVIDENCE: The last inspection report contained the following requirement: Service users’ rooms must contain all of the items listed in Standard 26.2, unless the service user has made a positive choice not to and this is evidenced in their files or recorded risk assessments show otherwise. This has not occurred and this requirement remains in force. {It is accepted that this requirement may have since been implemented but as the manager was not on duty at the time of this inspection, it was not possible to access all records to confirm if it had been met.} Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 17 The last annual inspection report recorded that there were no general or individual occupational therapist assessments for aids and adaptations available for inspection. In addition there were no specialist assessments or equipment for the service user with a sensory impairment or the service user that uses a wheelchair. The following requirement was then set to address this shortfall: The home must acquire an occupational therapist’s assessment for aids and adaptations for the general environment and individual service users. The shift leader could not produce the required documentation and this requirement remains in force. {It is accepted that this requirement may have since been implemented but as the manager was not on duty at the time of this inspection, it was not possible to access records to confirm if it had been met.} At this inspection three staff bags, two coats and a jumper were observed on furniture and the floor in the service users lounge. Staff do have separate facilities to store their belongings and should not infringe on the service users space. The following recommendation is set under Standard 28 to address this: Staff should use their separate facilities to store their belongings, and should leave bags and coats in the service users’ communal or individual space. The home was clean and tidy at the time of this unannounced inspection. The home has specific policies on the disposal of clinical waste, infection control and Control of Substances Hazardous to Health. There are laundry facilities with a sluice and an industrial type machine, which is capable of washing at high temperatures. The laundry is separate from the kitchen and has floors and walls that are easy to clean. Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. Please see the last inspection report for details regarding these standards. EVIDENCE: These standards were not assessed on this occasion. Please see the last inspection report for details regarding these standards. Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42. The residents now benefit from a new permanent manager which should provide continuity. Although progress has been made with regards to the home implementing a quality assurance system and an annual development plan, this still needs to be finalised. Without this, the involvement of the residents and relatives could be limited. Although the health and welfare of the residents is generally prompted, parts of the environment do not fully facilitate the residents’ health and well being. EVIDENCE: The last report recorded that here has not been a registered manager for some time. A requirement was set at the last announced inspection requiring a registered manager to be appointed. A new permanent manager has since been employed, which should provide continuity. Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 20 The last inspection report recorded the following: The deputy was previously covering the manager’s post. As the previous lack of a registered manager has not been addressed and there is now also a deputy’s post not being covered, the following new requirement is now set: The Trust must ensure that employment of any persons at the care home on a temporary basis will not reduce staffing in other areas and not prevent service users from such continuity of care as is reasonable to meet their needs. As a new permanent manager has since been employed the deputy can concentrate on their post. This requirement is also therefore now met. The last annual inspection report contained the following requirement: The home must pull together its Quality Assurance tools into a structured Quality Assurance system that makes the service users central to the process. The home should also ensure that an annual development plan is produced and is open to the service users, to allow measurement of achievement in improving quality. This requirement remains in force until fully met. {It is accepted that this requirement may have since been implemented but as the manager was not on duty at the time of this inspection, it was not possible to access records to confirm if it had been met.} At the last inspection, an up to date 5 year wiring certificate was not available. The following new requirement was then set to address this: An up to date 5 year wiring certificate must be sent into the Commission. This has not been received and this requirement therefore remains in force. At this inspection, the front gate was dragging on the floor whilst the inspector was trying to open it making it difficult to open. The following new requirement is set to address this: The front gate should be repaired to improve ease of use and access for the service users. Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 21 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 x x x x x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x x x Standard No 24 25 26 27 28 29 30
STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Inglemere Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x DS0000025798.V271360.R01.S.doc Version 5.0 Page 22 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 YA1 Regulation 5 12[3] Requirement Timescale for action 01/12/04 2. YA1 3. YA1 4. YA6 5. YA9 The Service Users Guide must contain the views of the service users. {Timescale of the 1/12/2004 not met}. 5 12[4]b The service users guide must be in a format that is suitable for the service users {Timescale of the 1/12/2004 not met}. 4[1][C] The Statement Of Purpose must specify room sizes and the S.O.P. and service users guide must contain the qualifications and in particular the relevant experience of the registered provider, manager and staff. {Timescale of the 1/12/2004 not met}. 15 A record of all of a service users needs and how they are to be met and by whom must be recorded in their plans of care. {Timescale of the 1/12/2004 not met}. 17[1]a 13[7] The home must produce risk assessments to evidence how safety outweighs choice where any restrictions of liberty or pre-planned restraints are assessed as necessary for the
DS0000025798.V271360.R01.S.doc 01/12/04 01/12/04 01/12/04 01/09/04 Inglemere Version 5.0 Page 23 6. YA9 7. YA12 8. YA18 9. YA23 10. YA26 11. YA29 protection of service users. {Timescale of the 1/9/2004 not met}. 13[7] Risk assessments must contain all the information required under Standard 9.4, and in particular, details of how training and other options have been explored and the involvement of relatives or independent advocates. {Timescale of the 1/9/2004 not met}. 16. The home manager must (2)(m)(n) develop the range of fulfilling activities available to service users in and out of the home. {Timescale of the 30/4/2004 not met}. 12[4]a b Staff must always provide adequate supervision, support and guidance for the residents. {Timescale of the 01/07/05 not met}. 17 12[1][4]b Guidance regarding the use of unplanned restraint and guidance regarding acceptable forms of restraint, and the use of other techniques to avoid restraint must be made available to staff and these procedures must be known by them. {Timescale of the 1/9/2004 not met}. 16[2]c m Service users rooms must contain all of the items listed in Standard 26.2 unless the service user has made a positive choice not to and this is evidenced in their files or recorded risk assessments show otherwise. {Timescale of the 1/12/2004 not met}. 12[1]a13[1]b The home must acquire an occupational therapists assessment for aids and adaptations for the general environment and individual
DS0000025798.V271360.R01.S.doc 01/09/04 30/04/04 01/07/05 01/09/04 01/12/04 01/12/04 Inglemere Version 5.0 Page 24 12. YA39 24,1,2,3 13. YA42 12 14 YA 42 12 service users. {Timescale of the 1/12/2004 not met}. The home must pull together 01/12/04 its Quality Assurance tools into a structured Quality Assurance system that makes the service users central to the process. The home must also introduce user/relatives satisfaction surveys and an annual development plan that is open to the service users, to allow measurement of achievement in improving quality. {Timescale of the 1/12/2004 not met}. An up to date 5 year wiring 01/07/05 certificate must be sent into the Commission. {Timescale of the 01/07/05 not met}. The front gate should be 31/03/06 repaired to improve ease of use and access for the service users. 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 YA6 YA14 YA17 Good Practice Recommendations Daily notes should be recorded daily and reflect how the care plan was implemented on that day. Each service user should be offered a seven-day holiday paid for by the home. The home should devise a coherent strategy for balancing a residents food choices with appropriate encouragement for nutritional requirements. This strategy should be recorded and its outcome included in daily notes. Staff should use their separate facilities to store their belongings, and should leave bags and coats in the service users communal or individual space. 4 YA 28 Inglemere DS0000025798.V271360.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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