Inspection on 23/10/07 for Laburnum House

This inspection was carried out on 23rd October 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Laburnum House 03/08/06

Laburnum House 07/12/05

Laburnum House 21/04/05

Laburnum House 14/09/04

Laburnum House 06/04/04

Laburnum House 28/10/03

Laburnum House 03/06/03

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

CARE HOME ADULTS 18-65 Laburnum House Second Drive Landscore Road Teignmouth Devon TQ14 9JS Lead Inspector Jo Walsh Unannounced Inspection 23rd October 2007 10:00 Laburnum House DS0000003733.V349315.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 Laburnum House DS0000003733.V349315.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. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Laburnum House Address Second Drive Landscore Road Teignmouth Devon TQ14 9JS 01626 774662 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) Rotel Ltd Vacancy Care Home 18 Category(ies) of Learning disability (13) registration, with number of places Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only- Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability- Code LD The maximum number of service users who can be accommodated is 13. 3rd August 2006 Date of last inspection Brief Description of the Service: Laburnum House cares for up to 13 adults with learning disabilities under 65 years old. A company called Rotel that owns two other homes for adults with learning disabilities in South Devon runs the Home. The Home is in a residential area of Teignmouth within walking distance of the town centre, bus routes and the train station. There is level access into the front of the Home, but steps throughout the rest of the building may present difficulties to someone with a mobility problem. All of the bedrooms are en-suite and single, with additional toilets, showers and a bathroom. Twelve of the bedrooms are in the main building with a selfcontained flat in the grounds. There are a number of communal rooms throughout the Home. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place during a weekday in October and lasted approximately 6 hours. During this time six people who live at the home were spoken to and two staff. Time was also spent with the manager discussing documents looked at. These included plans of care, staff files, training records, records relating to individuals finances, incident and accident reports and the fire log book. The regional pharmacist advisor for CSCI visited for the morning and spent time looking at the homes medication storage, recording and systems for administering medications. A tour was made of all communal areas and some of the individual bedrooms. Prior to the inspection the home completed some information about how they ensure the environment is well maintained and safe as well as staff recruitment and training. This information helps us to understand how well the home is run. Everyone who lives at Laburnum House was sent a survey prior to the inspection and 5 were returned. Staff were also sent surveys, two were returned. In addition we asked health care professionals and care managers about the home and their views are included in this report. What the service does well: Laburnum House provides a clean, homely and reasonably well maintained environment. All individual have their own bedroom and en suite and there are a good variety of communal areas to enjoy. Individuals have plans of care that are well written, and help staff to provide care and support in a consistent way. Person and health care needs are well met. One care manager commented in a survey ‘’ my client is complex and they (staff) have worked closely with appropriate services to address behavioural issue to facilitate their enjoying a better quality of life.’’ People who live at Laburnum House have opportunities to have a say on how they are supported. They have regular meetings to discuss, holidays, outings, activities, and menus and a resident representative meets regularly with the company directors to discuss any issues or suggestions they may have. In Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 6 addition the home uses surveys to ask individuals if they are happy with all aspects of care and support received. The home provides a good range and choice of meals, taking into consideration individuals likes and dislikes. What has improved since the last inspection? What they could do better: Plans of care should be developed and reviewed with the individual. Where a person refuses to take part in this process, this should be recorded. It would be useful if plans were developed in formats that people may understand easier, using photos and signs for example. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 7 Some improvements are needed to ensure that the records in respect of medications have an accurate audit trail. This refers to recording when a medicine is taken out of the home. Staff should work to encourage people who live at Laburnum House to be as independent as possible, including being involved in meal preparation. Current systems in place such as staff preparing packed lunches for the following day, does not allow individuals to develop their skills or be given a choice in what they wish to eat. The registered providers must ensure that staff files have clear evidence to show that all checks have been completed so that people who live at Laburnum House are protected from being exposed to staff that may not be suitable to work with vulnerable people. Staff need to be appropriately supervised and supported. This includes having the opportunity to have regular 1:1 supervision sessions with the manager. This ensures that any issues or training needs can be identified and resolved. All new staff must complete an induction programme that meets nationally recognised standards, and demonstrates that staff are competent and knowledgeable to do their job effectively. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Laburnum House DS0000003733.V349315.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 Laburnum House DS0000003733.V349315.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are only admitted to the home when assessments have been carried out to determine whether their needs can be met. EVIDENCE: The assessment information for the two newest people at the home was looked at and discussed with the manager, although she had not been involved in completing these. One was not very detailed, but this person had come as an emergency admission and there was detailed information available from the care manager. The other assessment was fully competed and it was clear that this individual had been assessed over a period of time and that they had been able to come and visit the home prior to moving in. The assessment information gave details of the person’s personal and health care needs as well as any risks. This information is then used to develop a plan of care. One member of staff said that they were given information about individuals prior to them moving in and both staff spoken to had a good understanding of individuals needs. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at Laburnum House benefit from having regularly reviewed plans of care, which reflect their individual needs and choices, although staff need to look at how they can encourage people to be more involved in all aspects of life in the home. EVIDENCE: Three plans of care were looked at in some detail. The are well organised and give a good picture of what the individuals abilities are, what they enjoy as well as what their needs are and how these should be supported. The plans have clear risk assessments and highlight any triggers for possible behaviour that challenge. Two of the plans had not been signed by the individual concerned. The manager stated that one person was likely to have refused, and it was agreed that if this was the case they home should record that the plan was shared Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 11 with them, but that they refused to sign it. The manager said that the other individual was unlikely to understand their plan of care. The home should look at how they can make plans of care more user friendly, including photos or symbols for example. If individuals are unable to take part in the development and review of their plans then the home could look to involve their family member or independent advocate if possible. People spoken to said that they are able to make choices, although this may be restricted by their risk assessments. For example one person said that they have to be on a strict diet due to a medical condition, so understands that staff have to support them to maintain this diet. One person said that they found going to day care too much to go all week and had been given the opportunity to attend for three days, and chooses to relax at home on the other two days. Staff spoken to were able to show how individuals were given choices in their everyday lives, giving examples such as being able to make drinks when they wished, helping to choose the menus and shopping. Both staff had a good understanding of risk assessments and demonstrated a good knowledge of individuals needs. One area that should be looked at is encouraging people to be more involved in activities of daily living, especially meal preparation. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at Laburnum House are able to take part in activities that suit their needs and wishes and are supported to access the local community and maintain family and friends contacts. EVIDENCE: The company who own Laburnum House, Rotel also have two other homes in the local vicinity and the offer day care for all these homes in a central location in Torquay called FOCUS 2000. The day service is run five days per week and transport is provided for this. The day service offers a range of activities both educational and recreational. The people who live at Laburnum House attend this day service up to five times per week. The day care service have regular meetings and minutes of the last one had a list attached of other activities that people had asked to be included. Two people said they enjoyed going to Focus 2000 and one said they liked the trips out they organised and talked about a trip they had been on to the zoo. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 13 Some people are involved in work experience and some attend college to access course suitable to their needs. People are supported to access the local community for shopping, some are able to access the local shops independently. Staff said that they encourage people to go out on trips and outings as much as they can, although staffing does not always allow for individualised outings. One person said they went out often and enjoyed spending time out and about. People are supported to stay in touch with their family and friends via letters, phone calls and visits. One person said they went to Greece every year to meet up with family and staff helped them to do this. One person said that staff helps them to write to family members overseas and to take them to visit family who live locally. Letters are given to people unopened. The manager was observed discussing a bank circular with one person explaining what it was in away that the person would understand. Individuals sexuality was not directly discussed, but there is a section in individual plans of care that covers this area and shows that the home have given thought to how individuals may wish to express their sexuality. The menu plan was looked at and discussed with a member of staff. There appears to be a good variety and choice available and individual likes and dislikes are taken into consideration when menus are planned. People who live at the home said ‘’ I like the meals, yes the food is okay, my diet is monitored by staff, they make sure I have lots of vegetables to help fill me up,’’ It would benefit individuals to be more involved in the preparation of meals. For example it was noted that the sandwiches for the following days packed lunch had already been prepared before they had got back from day care. This does not encourage individuals to be more independent or give them a choice about what to put in their sandwich. The staff team need to ensure that opportunities are given to encourage people to help and participate in meal preparation more. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at Laburnum House are supported in their personal and health care needs in a way that suits them. Medicines are on the whole well managed in the service although there are some areas that need improvement EVIDENCE: Plans of care looked at give clear direction to staff to ensure that care and support is provided in a consistent way. Health care issues are clearly identified and any specific issues are followed up. One care manager commented ‘’ my client is complex and they (staff) have worked closely with appropriate services to address behavioural issue to facilitate their enjoying a better quality of life.’’ Daily records show that staff are aware and comment on individuals emotional well being, and 1:1 time with key workers allows individuals to talk about any issues that might being causing them concern. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 15 We found that the home has in place a good system to record the receipt of medicines into the home. However we found that when medicines are taken out of the home there is no record of these medicines being taken out of the home or being returned to the home if not used. We also found that the home have clear individual protocols for how medicines prescribed to be administered “when required” are to be used. We found that although all medicines were stored securely some prescribed nutritional supplements were not stored within the temperature range as specified by the manufacturer, although arrangements were made at the inspection to correct this. We found that all administrations of medicines had been recorded on the Medication Administration Record charts, however the records made by some members of staff were unclear as they had only used one of their initials and this then looked like one of the codes at the bottom of the chart for reasons why medicines had not been given. We found that staff had received training in the administration of medicines and were told that staff had received some specialist training. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s views are listened to and acted upon, but improvements are needed to ensure that individuals are fully protected from possible abuse. EVIDENCE: People who returned surveys and several who were spoken to said they knew who to complain to if they had a concern, one person said ‘’ my carers always sort any issues out for me they are really great and I love them’’ The home has a stated complaints procedure that is in an easy read format and is posted in various parts of the home. Resident meeting minutes were seen and they record that everyone is asked if they have anything they want to raise. Since the last inspection one complaint has been received by the commission and was passed to the provider to investigate. We are satisfied this was appropriately looked into and responded to. Complaints received by the home are recorded and actions taken to resolve issues appear appropriate. Staff files checked did not contain all the information that would show that checks had been completed to ensure that new staff were suitable to work with vulnerable people. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Laburnum House is a clean, reasonably well maintained and homely environment that people who live there feel comfortable in. EVIDENCE: During this inspection all communal areas and some of the individual bedrooms were looked at. All parts of the home were clean and fresh smelling. One staff member said they do not currently have a cleaner so staff work hard to maintain a good standard of cleanliness. The carpet in bedroom 7 is very worn near the patio doors and could present as a trip hazard. This must be replaced at the earliest opportunity. The manager was asked that in the interim, they secure the worn area with tape to ensure it is safe. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 18 The communal areas are bright and spacious and there are pictures of holidays and canvas art works up that individuals had done, which added to the homely feel. It was noted that there was no soap or paper towels in one of the communal toilets and a staff member replenished the supply straight away. They explained that one person who lives at the home was likely to remove these on a regular basis. It is suggested that the home look at having holders for the soap and towels to deter people form removing them. This will help to reduce risk of infection. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People at Laburnum House are supported by a staff team that are trained and relatively well supported to do their job. EVIDENCE: Three staff files were looked at during this inspection. Not all the information was available to show that the providers have had ensured that staff were fit to work with vulnerable people. (Two files did not contain CRB or any reference to a POVA first check being completed.) The registered provider said that this information would be at their head office, and said that they always ensured checks were completed prior to a new person starting. In order to fully comply with the regulations, the providers must ensure that this information is kept available in the home for inspection. This will help us to check that that people who live at Laburnum House are fully protected. Staffing levels appear sufficient to meet the needs of the current people who live at Laburnum House, although two staff said in their surveys that more staffing would enable them to offer more outings and activities at the weekends. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 20 Staff spoke to said that they have good training opportunities and half of the staff group have achieved a nationally recognised certificate in care and a further two are working towards completing this. This helps the staff team to understand their role as carers. The registered providers ensure that staff have training in areas of health and safety and following the last inspection the manager has devised a spreadsheet that helps to identify when this key training needs updating. Not all staff have received regular 1:1 support and supervision, including a new member of staff who has worked at the home for seven months and to date has had no supervision and a member of staff who provides one to one support for one individual and works in some isolation to the rest of the staff team. Supervision provides staff with an opportunity to reflect on their care practices and is an effective way of ensuring care and support is provided consistently as well as being a tool for looking at individual training needs. Induction training for two staff members was looked at. One staff member had completed this training but some areas had been signed as not applicable. They have therefore not completed the whole process. It is unclear if the induction training meets national standards and covers all key areas. The registered providers will need to check this out to ensure that all new staff has appropriate initial training. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live at Laburnum House benefit from a service that is well run and there are systems in place to ensure their views are considered in reviewing the care and support offered. EVIDENCE: The manager is going through the process of applying to register with the commission. She has a good knowledge of the individuals needs, but will need support to further develop her management skills. She is working towards completing the registered managers award that this will help to equip her with skills and knowledge needed to competently run the home. Staff spoken to and those who completed surveys said that they usually met with the manager on a regular basis and their opinion was listened to. Two surveys mentioned that the manager should be more understanding if there Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 22 was a problem. No further details were available so it was difficult to follow this up. It has already been highlighted that the manager should ensure that all staff has regular supervision at least 6 times per year. Since the last inspection the home have introduced surveys to people who live at the home, their families and to care managers. This will help to develop how the home plans to improve the service for the future. Any surveys completed should be reported upon and results made available to the people who live at the home and to CSCI. Other ways the home helps to listen to the views of the people who live there are by residents meetings, 1:1 key worker sessions where individuals are asked what they would like to see to improve their lives and by having a representative on a management board, to feed back to the providers any issues and ideas people who live at the home may have. Copies of minutes of these meeting were available for inspection. The information the home provided prior to the inspection details that checks are made on all equipment and that the home is well maintained and kept safe. Staff complete training in all areas of health and safety, and the basics of these are covering during the induction process. The induction programme should show how it links to the skills council and all areas need to be completed by all new staff. The registered provider needs to ensure that their quality audit includes room checks. The carpet in one bedroom needs replacing as a matter of urgency as it is a trip hazard. During this inspection the fire logbook was checked to ensure that weekly checks on all fire safety equipment is completed. We also checked records relating to personal monies and these were well maintained and provided a good audit trail. This helps to protect individuals. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13(2) Requirement A record must be made of all receipts of medicines and also of any medicines leaving the premises. The carpet in room 7 must be replaced as it is a potential trip hazard. The registered providers must ensure that staff files contain evidence of all relevant checks being completed and these must be available for inspection Timescale for action 31/12/07 2. 3. YA24 YA34 13(4) a 17 31/12/07 31/12/07 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 YA6 YA7 Good Practice Recommendations Plans of care should be in formats that individuals can understand and evidence recorded that they are involved in the development and review of these plans. Staff should be aware of the equality and diversity barriers that residents face, and be actively findings ways through them. Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 25 Laburnum House should have a policy on behaviour management and physical intervention. 3. 4. 5. YA17 YA36 YA39 Service users should be actively supported to help plan, prepare and serve meals All staff should have regular supervision sessions at least 6 times per year and this should be recorded. The Quality Assurance system should result in an annual development plan and feedback to participants. Copies of any results of surveys should be sent to CSCI. All new staff should complete all sections of the induction programme, 6. YA42 Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Laburnum House DS0000003733.V349315.R01.S.doc Version 5.2 Page 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. 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