Inspection on 20/09/06 for International Eating Disorders Centre

This inspection was carried out on 20th September 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 found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

International Eating Disorders... 02/10/08

International Eating Disorders... 26/10/07

International Eating Disorders... 02/03/06

International Eating Disorders... 14/12/05

International Eating Disorders... 05/10/04

International Eating Disorders... 24/02/04

International Eating Disorders... 31/03/03

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

CARE HOME ADULTS 18-65 International Eating Disorders Centre 119/121 Wendover Road Aylesbury Buckinghamshire HP21 9LW Lead Inspector Nichola Cahill Unannounced Inspection 20th September 2006 09:30 DS0000019232.V304783.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 DS0000019232.V304783.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. DS0000019232.V304783.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service International Eating Disorders Centre Address 119/121 Wendover Road Aylesbury Buckinghamshire HP21 9LW 01296 330557 01296 339209 enquiries@eatingdisorderscentre.co.uk 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) Dr Clarke Douglas Muzondo Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places DS0000019232.V304783.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons aged 16 years and above with Eating Disorders Date of last inspection 2nd March 2006 Brief Description of the Service: The International Eating Disorders Centre (IEDC) is a registered care home providing care, a programme of treatment and accommodation for nine service users with an eating disorder. It is located about a half mile from Aylesbury town centre. The home has been converted to form one large house. There is parking to the side and rear of the home. The home is conveniently situated for the amenities of Aylesbury. The home describes its treatment programme as having four phases: preadmission assessment, in-patient care, partial care and aftercare. On admission service users enter a highly structured five-stage treatment and rehabilitation programme to which they and their families consent before admission. The home is staffed by a multidisciplinary team, which includes medical staff (including a consultant psychiatrist), nursing staff, a consultant psychologist, counsellors, a dietician, cook, and healthcare assistants. Because of the specialist nature of this service it is not possible to assess it against all of the standards in ‘Care Homes for Adults (18-65)’. This applies in particular to those standards in which service user autonomy and independence feature. However, because the home admits young people of 16 and 17 years of age it is subject to the supplementary standards for care homes accommodating young people of those ages. Service users on the IEDC programme agree to give up a degree of autonomy and independence for a while in exchange for an opportunity to gain greater control over their lives. Information regarding the services offered is available on request. Care fees are £425.00 per day. DS0000019232.V304783.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 20th September 2006 by Nichola Cahill (inspector). The inspection took place over a period of 12 hours, this included the pre-planning. The focus of the inspection was to assess all key standards. The inspection methodology consisted of discussions with the manager, the staff on duty, a private discussion with three service users, a tour of the building and examination of records. Five comment cards were received prior to the inspection. Progress made on the requirements of the previous announced inspection was assessed and compliance noted. A full feedback of inspection findings was given to the manager, Douglas Muzondo and the registered provider, Dr Clarke. What the service does well: Service users receive information regarding the services that the home will offer and are ensured that their needs will be met through a thorough preadmission process. Service users have a care plan, are fully supported in making decisions regarding their wishes and aspirations and appropriate risk assessments are carried out regarding their clinical needs. Service users are supported in their personal development, education and occupation, retaining links with the local community, friends and family and are able to engage in appropriate leisure facilities. Service users are able to maintain appropriate and full filling lifestyles in and outside of the home. A nutritious diet is available ensuring assistance with service users recovery. DS0000019232.V304783.R01.S.doc Version 5.2 Page 6 The home provides appropriate support with personal and health care needs to ensure the needs of service users are met. Service users are empowered to air their concerns and complaints. Service users are provided with a homely, comfortable, clean and hygienic environment, which is appropriate to their lifestyle, and, there for, has a positive impact on their recovery. Adequate recruitment practices protect service users against potential abuse. The day-to-day management allows for the home to be run in the best interests of the service users. The service users are protected by most of the health and safety systems in place, addressing shortfalls in this area will further enhance such protection. What has improved since the last inspection? What they could do better: Lack of documented information regarding the social aspect of the care needs and inherent risks does not ensure that such needs will be fully met. Shortfalls in some areas of medication recording and storage systems could, potentially, put service users safety at risk. Shortfalls in abuse awareness and protection training do not ensure that service users are adequately protected at all times. A shortfall in staffing numbers and training does not ensure service users safety at all times. DS0000019232.V304783.R01.S.doc Version 5.2 Page 7 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. DS0000019232.V304783.R01.S.doc Version 5.2 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 DS0000019232.V304783.R01.S.doc Version 5.2 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, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users receive information regarding the services that the home will offer and are ensured that their needs will be met through a thorough preadmission process. EVIDENCE: Service users confirmed that they had received a copy of the service users guide on admission to the home. However, although comprehensive and informative in most areas, it was reported by service users that other areas were not a true reflection of life in the home. The document did not include arrangements for receiving visitors or any supplement information regarding the care of 16 and 17 year olds. It is recommended that improvements be made in this area. Permission was given from three service users to view their care files. A preadmission assessment had been carried out in consultation with the service users, relatives and representatives and other professionals involved in the care of each service user. It was confirmed by service users that they were afforded the opportunity to visit the home and to receive advise by telephone prior to admission. DS0000019232.V304783.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users have a care plan, are fully supported in making decisions regarding their wishes and aspirations and appropriate risk assessments are carried out regarding their clinical needs, however, lack of documented information regarding the social aspect of the care needs and inherent risks does not ensure that such needs will be fully met. EVIDENCE: Care plans were discussed with three service users and permission given to view each care plan file. Care files contained information regarding identified needs and objectives from a clinical perspective and appeared to deal with all health needs relating to the eating disorder diagnosis. Care plans identified the levels of observation that the service users required under the homes treatment regime. Service user input was clearly evident with regard to this aspect of their care. However, there was little evidence of the assessment and care planning for the social aspect of service users care. This would include education and DS0000019232.V304783.R01.S.doc Version 5.2 Page 11 occupation, access to the community, information regarding relationships with family and friends outside of the home or wishes and aspirations for the future. Service users reported that they were encouraged to participate in social activities and were clearly supported; this was not evident within care plan documents. A requirement has been made for improvement in this area. Service users make the decision to be admitted to the home and agree to a programme, which limits their decision-making. The level of observation determines the service users freedom and decision making within the home and service users are able to make choices within the framework of the programme. The home advertises advocacy services and receives regular visits from a Chaplin. Risk assessments had been carried out with regard to the clinical needs of service users; these documents did not cover the every day risks that may occur within any care home environment. A requirement has been made for improvement in this area. DS0000019232.V304783.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are supported in their personal development, education and occupation, retaining links with the local community, friends and family and are able to engage in appropriate leisure facilities. Service users are able to maintain appropriate and full filling lifestyles in and outside of the home. A nutritious diet is available ensuring assistance with service users recovery. EVIDENCE: On level 3 and 4 of the programme service users have opportunities to maintain and develop social and independent living skills. Service users on level 4 are encouraged to live in the flat attached to the home to enable them to develop those skills in preparation for discharge. All service users have individual key sessions with the psychologist and with their key worker. Service users are also required to attend group sessions. Each of these should support service users to communicate their feelings, to explore their problems and positive ways of dealing with them. DS0000019232.V304783.R01.S.doc Version 5.2 Page 13 Service users reported that they had been through a difficult period of late due to the departure of the two permanent psychologists, however, two sessional physiologists had been employed and the programme was improving for individuals. However, it was also reported that there was insufficient staff on duty to ensure the needs of service users are fully met at all times. This was confirmed through observations made and from discussions with staff. Staffing numbers are discussed further within this report. It was confirmed that individuals spiritual needs are met and that a spiritual growth meeting is held daily – attendance is optional. The Chaplin was visiting the home at the time of the inspection. All service users are expected to participate in the weekly planned programme of activities. On the day of the inspection visit one service user was attending their own day activities and others had arranged to go into town for coffee. It has been previously discussed within this report that evidence of the assessment of all social care needs must be documented within care plans for individuals. On level one of the programme service users are unable to take part in work placement, training or education. As service users progress through the levels they would be supported to return to further education, training, or a work placement if they wish. On level four of the programme service users are able to access community resources independently. On level two and three of the programme service users can access community resources with staff support. The home has a folder with information on local activities. The home is on a bus route to the town centre and has its own transport, which is used to take service users for appointments or for trips out. Activities out of the home have to be planned in advance to ensure that there is a sufficient mix of staff on duty to cover both the outing and the home. It was confirmed that service users can see visitors on any level of the programme if they wish. At the time of the inspection visit the manager confirmed that visiting arrangements for service users was presently being reviewed within the treatment programme. It has been previously discussed within this report that the service users guide must indicate the arrangements for visits to the home. Service users have three meals a day with drinks available as required. Snacks are supplemented for individuals as outlined by the dietician. It was confirmed that the dietician visits weekly, sees service users individually and agrees a menu plan. Service users are expected to eat their meals in the dining room. A staff member eats with the service users and service users are observed following meals. Service users are expected to go to the toilet before meals and the toilets are then locked and can be only accessed with staff permission. DS0000019232.V304783.R01.S.doc Version 5.2 Page 14 Service users reported that they were happy with the arrangements for meals as part of their treatment and that the full time cook was extremely accommodating to individual needs. DS0000019232.V304783.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home provides appropriate support with personal and health care needs to ensure the needs of service users are met. Shortfalls in some areas of medication recording and storage systems could, potentially, put service users safety at risk. EVIDENCE: Service users on levels one and two observation are assisted with their personal care where necessary, at the time of the inspection service users in residence did not require this level of assistance. During the week service users are expected to get up for breakfast and take an active role in the daily programme. Service users are expected to be in bed by 23.30 hours during the week. There is more flexibility with times of getting up and going to bed at weekends. The daily routines within the home are specific to individual service users and the level of programme they are on. The home has a wheelchair if required for individuals and specialist mattresses to prevent pressure sores for service users on level one of the programmes. The bathroom has handrails. The home is able to access physiotherapy input DS0000019232.V304783.R01.S.doc Version 5.2 Page 16 as required and service users have regular input from a Psychiatrist, Psychologist and a dietician. District nursing care would be accessed via the GP. The medication administration records seen showed gaps in administration. The appropriate codes were not used to indicate why medication was not given. Medication was being stored for service users no longer residing in the home. Requirements have been made for improvement in this area. Service users are encouraged to be responsible for the administration of their medication with staff supervision and the appropriate risk assessments are in place. It was discussed that service users should be afforded the choice of where they store their own medication and could be provided with a safe storage area within their own bedroom space. At present this is all stored in one central cupboard in the managers office. A recommendation has been made in this area. DS0000019232.V304783.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users are empowered to air their concerns and complaints. However, shortfalls in abuse awareness and protection training do not ensure that service users are adequately protected at all times. EVIDENCE: The home has a comprehensive complaints procedure, which is outlined within the service users guide. Service users all confirmed that they had a copy of this document and that they found staff to be approachable should any issues arise. The home has received one complaint since the last inspection visit. The manager had investigated this complaint and all documentation regarding actions and outcomes was in place. The home has policies and procedures in place for the protection of adults and children; these were not viewed at the time of this inspection visit. All staff employed are subject to the appropriate pre-employment checks. Five of the thirteen staff have received training in the protection of vulnerable adults, however, no training has been completed, with the exception of the manager, in the protection of children from abuse. The manager has recently completed a ‘train the trainer’ course in protection of vulnerable adults and is in the process of disseminating this training. A requirement has been made for improvement in this area. DS0000019232.V304783.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are provided with a homely, comfortable, clean and hygienic environment, which is appropriate to their lifestyle, and, there for, has a positive impact on their recovery. EVIDENCE: The home is located about a half a mile or so from Aylesbury town centre. It is on the main road and easily accessible by car or bus. The style of the building is in keeping with others in the locality. Only the ground floor is accessible to a wheelchair user. Coded locks control access to the building. The ground floor comprises entrance hall, the staff office, residents’ accommodation, bathrooms and WC’s, the lounge and conservatory. The first floor comprises of the administration office, consulting rooms, a meeting room, kitchen, dining room, wc’s, and a ‘partial care’ flat which may be used by service users on level 4 of the programme. All areas of the home were clean and tidy. Most areas have been redecorated. DS0000019232.V304783.R01.S.doc Version 5.2 Page 19 Three service users gave permission for their bedrooms to be viewed. The rooms were well furnished with bed, desk, chair, armchair and wardrobe and were reflective of the individual services users tastes. Rooms do not have a sink because of the specialist nature of the service. The colour scheme varied from room to room. The lounge is a good sized room. The amount of seating is sufficient for the number of residents. A TV, freeview box, DVD and video recorder were available for residents. There were sufficient electrical sockets for the amount of equipment and lighting in the room. The home had a comfortable, homely and non-clinical feel, it was discussed with service users that this homely ambience had been an important factor in their choice of home and their recovery. DS0000019232.V304783.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Adequate recruitment practices protect service users against potential abuse, however, shortfalls in staffing numbers and training does not ensure service users safety at all times. EVIDENCE: Since the last inspection visit the home has suffered the upheaval of some staff leaving and the use of agency staff. It was reported that this had had an impact on the treatment programmes for service users. However, service users reported that there were now less hours used by agency, two new health care assistants and two new sessional psychologists had been employed, there for there were improvements in this area at the time if the inspection visit. Through observations made and discussions with service users and staff it would appear that the numbers of staff on duty during the day is not sufficient to meet the needs of the service users group. It was noted that the manager is counted as the nurse on duty and is only accompanied by one health care assistant. The constant management duties do not allow uninterrupted care for service users. At the time of the inspection there were five service users residing in the home, the home is registered for nine. Service users and staff also reported that during the afternoon / evening period the health care assistant is responsible for preparing and cooking the evening meal and any other snacks. Due to the location of the kitchen this DS0000019232.V304783.R01.S.doc Version 5.2 Page 21 only leaves one member of staff on duty on the ground floor at all times. Health care assistants are also responsible for the daily laundry and for serving all meals during the weekend period. A requirement is made for improvements in this area. The recruitment files were viewed for two new health care assistants recently employed. All pre-employment checks had been carried out satisfactorily. One new member of staff was ‘shadowing’ another during her induction period. Staffs training files were viewed. From the records stored within the file it would appeared that there were many shortfalls in all training areas. The manager confirmed that some records were not up to date and provided the Commission with a new training matrix. This matrix shows that there are still shortfalls, however, these are minimal. The manager is respectfully reminded that all records must be kept up to date at all times. A requirement has been made for improvement in this area. DS0000019232.V304783.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The day-to-day management allows for the home to be run in the best interests of the service users. The service users are protected by most of the health and safety systems in place, addressing shortfalls in this area will further enhance such protection. EVIDENCE: The manager, Douglas Muzondo, was registered with the Commission in July 2006. Mr Muzondo holds recognised qualifications in nursing and mental health; he is currently due to complete his management in care certificate with the Open University. Service uses spoke highly of the manager and staff of the home and were encouraged by their care skills and their dedication in supporting them in their recovery. Despite shortfalls in staffing numbers and some other areas of training and care planning the service users appear to benefit from a well run home which is run in their interests. DS0000019232.V304783.R01.S.doc Version 5.2 Page 23 Quality assurance was discussed with the manager; however, quality assurance documentation was not assessed during this inspection visit. This will be one focus for the next inspection visit. Health and safety information was viewed as follows; • Fire records showed that systems had been serviced on 11/09/06. Fire alarm testing had been carried out, however, records were confusing and difficult to follow. This was discussed during the feedback session. • COSHH data was in place for all products used. • Gas systems had been serviced on 09/11/05. • PAT testing had been carried out in November 05. • It was recommended that the front door code be changed periodically to protect the safety of service users at all times. • It was noted during the visit that some doors were wedged open periodically with chairs, boxes and other items. These items were removed at the time of the inspection. The manager is respectfully reminded that wedging open any fire door is a clear breach of regulation and could have serious implications for service users and staff. DS0000019232.V304783.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 2 2 x 3 3 4 x 5 x 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 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 2 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x x x x 3 x DS0000019232.V304783.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 Requirement It is a requirement that the home carries out an assessment and care planning for the social aspect of service users care. This would include education and occupation, access to the community, information regarding relationships with family and friends outside of the home or wishes and aspirations for the future. It is a requirement that risk assessments cover the every day risks that may occur within any care home environment. It is a requirement that medication administration charts are completed appropriately and unused medications disposed of correctly. It is a requirement that all staff receive update training in adult and child protection. It is a requirement that there are adequate numbers of staff on duty at all times to meet the assessed needs of the service user group. It is a requirement that all staff training is brought up to date and DS0000019232.V304783.R01.S.doc Version 5.2 Timescale for action 30/11/06 2 YA9 13 30/11/06 3 YA20 13 30/09/06 4 5 YA23 YA33 13 18 31/12/06 31/12/06 6 YA35 18 31/12/06 Page 26 that evidence is available for all courses attended. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard YA1 YA20 Good Practice Recommendations The service users guide should be updated to ensure an appropriate reflection of day-to-day life in the home. It is recommended that the home consult with service users regarding the storage of medication. DS0000019232.V304783.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000019232.V304783.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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