Inspection on 14/06/06 for Larklands And Church View

This inspection was carried out on 14th June 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Larklands And Church View 27/07/07

Larklands And Church View 21/09/05

Larklands And Church View 13/04/05

Larklands And Church View 27/10/04

Larklands And Church View 11/05/04

Larklands And Church View 13/01/04

Larklands And Church View 01/10/03

Larklands And Church View 04/06/03

Larklands And Church View 23/07/02

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

CARE HOME ADULTS 18-65 Larklands And Church View St Johns Road Ilkeston Derbyshire DE7 5PA Lead Inspector Anthony Barker Key Unannounced Inspection 14 & 15th June 2006 09:10 th Larklands And Church View DS0000002171.V297877.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 Larklands And Church View DS0000002171.V297877.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. Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Larklands And Church View Address St Johns Road Ilkeston Derbyshire DE7 5PA 01522 560950 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) United Health Limited David Wagstaff Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2005 Brief Description of the Service: Churchview and Larklands is a purpose built care home with nursing offering 10 places for adults with a severe learning disability, set in 2 bungalows. It is close to the town centre of Ilkeston with easy access to local facilities. Its physical environment was designed for the current group of residents who were all admitted in 2000 as part of the closure of Aston Hall Hospital. Because of the high levels of learning disability in the resident group the Home offers an intensive package of support and the number of staff is accordingly set high. Its fees are currently £1151.28 per week. Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 11.5 hours and was a key unannounced inspection. The last inspection took place in September 2005 and was unannounced. The residents had high levels of dependency and therefore were not able to contribute directly to the inspection process, though they were observed throughout the visit working with and being cared for by staff. The Manager, Deputy Manager, two social care workers and a visiting Macmillan Nurse were spoken to and records were inspected. There was also a tour of the premises. Three residents were case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 6 A written protocol, on the use of ‘prn’ - as and when required – medication, must be provided for all residents who have this medication. These protocols must be explicit. The recording of the administration of prn medication on Medication Administration Record (MAR) sheets must be clear and consistent. The bathroom and shower room doors must be provided with internal devices that would prevent a resident, or staff member, being locked in the room. 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. Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. 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. Residents’ individual needs had been fully assessed before their admission to the Home. EVIDENCE: There had been no new admissions in recent years and Standard 2 had been assessed as met, at previous inspections. Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 9 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 & 9 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents’ needs, and the risks to which they were exposed, were reflected within their individual care plans. They were being enabled to make decisions about their lives and were supported to take risks as part of their personal development. EVIDENCE: The files of the three case-tracked residents were examined. Action Plans were well worded and extensive in their coverage of personal health and behavioural needs. They were being reviewed either three or six monthly. Each resident had a Life Story Book that provided a valuable record for staff. Social needs were scarcely mentioned in the Action Plans although recorded risk assessments did address risks associated with activities, such as swimming. Residents’ ‘likes and dislikes’ were only noted on one case-tracked resident’s Life Story Book. However, there was evidence that residents’ social needs were clearly being identified and met. Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 10 Staff cited several examples of residents making decisions and choices. These ranged from a resident deciding to stay in his bedroom to a request to take a trip out. Some of these decisions had associated risks attached and it was clear that staff responded both sensitively and with due care. Recorded risk assessments were of a high standard and were being reviewed regularly. They not only addressed individual residents’ safety but also referred to the need to maintain residents’ dignity in the context of challenging behaviour in public places. There was evidence, during this inspection, that risk management was not just a paper exercise. Discussions with staff indicated that the Home was regularly practising ‘responsible risk taking’ to enable residents to develop confidence in daily activities. Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 11 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 this service. Residents were being supported to take part in valued and fulfilling activities – a number of these being within the local community. Residents’ rights were being respected and family links were maintained. Residents were being offered a healthy diet. EVIDENCE: There was evidence of residents taking part in valued and fulfilling activities. For example, staff reported that residents show excitement at a ‘sounds and movement’ group, First Movement, that they attend in Derby. It was clear that staff search for interests specific to individual residents. Residents’ attendance at an advocacy group, in Bakewell, helps to achieve this aim. A full time Activities Coordinator has been employed since January 2006 and one staff member considered that the residents seem more relaxed now. Her activities include weekly music nights and the use of the Art Room in Larklands. A Weekly Activities Board, seen in both bungalows, highlight each resident’s daily activities and files contained ‘Activities Social/Leisure’ sheets Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 12 providing valuable written feedback on these daily activities. All except one resident, on personal health grounds, were being provided with at least one holiday a year, with two to one staffing. Case-tracked residents’ files provided evidence of their involvement in the local community. The local swimming pool was one valuable resource, just 10 minutes away, and residents also spent time in a local pub, the barbers and shopping for clothes, toiletries and food. Staff and residents walked into the local community, or used wheelchairs; public transport was used and the Home had a mini bus. Family contact with some residents was limited while with others it was regular, staff reported. Relatives visited the Home and took residents out. While residents generally related to staff, within the Home, there was evidence of a close relationship between two residents and staff spoke of them “enjoying each other’s company”. These two residents had known each other at Aston Hall Hospital before their admission to the Home. Staff provided examples of how residents’ privacy and dignity were respected. During the inspection, staff were observed knocking on bedroom doors before entering and talking respectfully to residents. All residents needed some degree of prompting as part of their personal daily routines and some required physical help – with dressing or toileting, for example. Each bedroom door was lockable and keys were kept outside the room, either in the door lock or hung beside the door. Residents had unrestricted access to their rooms. Hot and cold water supplies, to all taps to which residents had access, were controlled by a key-operated switch. Some residents were prone to drink excessively and this system addressed their personal safety, as well as minimising the risk of flooding. Key pads were fitted to a number of doors to address residents’ safety and hygiene (kitchen door). Residents’ levels of disability precluded them have allocated housekeeping responsibilities although the Manager explained that some residents would bring back their cleared plates to the kitchen and staff led periodic baking sessions. The Manager and staff were observed to be providing residents with the boundaries they needed for their security and welfare in a very personalised, caring and noninstitutional way. This central aspect of the Home’s provision was considered to exceed minimum standards. A mealtime was observed at this inspection and food looked appetising. Residents generally seemed to be enjoying their meal. Food stocks in the kitchen were satisfactory and included fresh fruit and vegetables. A two-week rolling menu was sent with the pre-inspection questionnaire and this showed that residents were being provided with a varied and nutritious diet. Menu books provided a record of food actually eaten – particularly important for those residents with dietary needs. Several ‘theme nights’ a year were held, the Manager explained. Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 13 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 this service. Residents were receiving personal support in the way they prefer and require. Their physical and emotional health needs were being met. However, they were not being fully protected by the Home’s procedures for dealing with medicines. EVIDENCE: Staff provided evidence of there being flexibility within daily routines – mealtimes and bedtimes may be later than usual following an activity or a relative’s visit, for instance. Residents can rise each morning when they want to, though individual health needs may dictate limits to this flexibility. Equipment in place to maximise residents’ independence included two ‘Parker’ baths and one walk-in shower, eating aids and a ‘Rompa’ swing seat in the garden. Hoists were not considered necessary – most staff had been provided with Moving & Handling training, the Manager stated, and this was later confirmed from records. Four nursing staff had received Makaton (sign language) training and Makaton symbols and photographs were used with one resident to help him express his needs and preferences. Photographs were used with another resident to expand his use of words. Discussion took place with the Manager about using photographs or other means to make a pictorial Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 14 representation of food - to further enable residents to make choices and decisions about what they eat. An advocate with Derby Advocacy Service was involved with all the residents and was attending each of the formal sixmonthly care plan review meetings. She had been advocating for additional resources for the residents. Case-tracked residents’ files showed details of a good range of external health professional contacts and provided evidence of health appointments being met and residents’ health needs being well considered. Some of the residents had complex health problems and the nurses and care staff were well supported by the local GP practice. A Macmillan Nurse has been visiting the Home monthly for the past two years – providing advice to staff on symptom management regarding one resident’s cancer. Her visit coincided with this inspection and she spoke positively about her relationship with the Home, referring to “good team working”. One resident had been provided with a ‘ripple mattress’, and a specialist chair, and these had successfully prevented the occurrence of pressure sores. The Deputy Manager referred to a risk assessment addressing this resident’s tissue viability. Medication Administration Record (MAR) sheets were examined and were generally satisfactory. There was a record of sample staff signatures/initials and photographs of each resident, to minimise mistakes. Five residents were being administered medication on a ‘prn’ - as and when required – basis. There were ‘prn protocols’ for only two of these residents. One referred to administration of medication when behaviour was “aggressive and inappropriate”. This could be interpreted differently by different staff. The recording of the administration of prn medication on MAR sheets was inconsistent and sometimes unclear – for example, there was no time recorded against one entry. There was no general written policy on the use of prn medication. Case-tracked files had residents’ provisional funeral arrangements recorded. Other aspects of standard 21 were not assessed on this occasion. Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 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): Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents were benefiting from a comprehensive complaints procedure and were being protected from abuse by a robust set of Adult Protection procedures. EVIDENCE: The Home had a comprehensive complaints procedure. There was no paper recording system, in the Home, for complaints received although a copy of a suitably worded Complaints Form was later sent to the Commission and a complaints Follow-up Sheet was on computer in the Home’s office. The latter appropriately addressed a complainant’s satisfaction with the outcome. The Manager reported that there had been no formal complaints made by anyone within the past 12 months. All residents had external professionals, and an advocate, looking after their interests. There had been no adult protection investigations since the last inspection. On two previous occasions the local Social Services Office had been involved and the Home’s management and staff were seen to act swiftly in order to protect the residents. The need for more Adult Protection training for the staff group arose from those events and one of the Home’s staff nurses had undertaken a ‘training for trainers’ course in Adult Protection and was planning to provide additional training to staff, soon. The Manager and Deputy Manager had undertaken Adult Protection training with Derbyshire County Council (DCC). The Company’s written procedures on Adult Protection were brief and referred to DCC’s procedures for more detail. A copy of these were being held at the Home. A comprehensive Whistle Blowing policy was seen and one member of Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 16 staff expressed her confidence in this policy. She also spoke of having received in-house training on Adult Protection. Larklands And Church View DS0000002171.V297877.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 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 this service. Residents were living in a homely and generally safe environment, although one matter needed attention in order to fully comply with safe working practices. The Home was clean and hygienic. EVIDENCE: Environmental standards were good at this Home, particularly considering the challenging behaviour of some of the residents, and there was no institutional feel to the environment. There was evidence of these standards improving, in line with residents’ improving behaviour. The Home was nicely decorated and was quite homely. A number of bedrooms were well personalised. A replacement ‘Parker’ bath had been provided at Larklands, three bedrooms had been redecorated and the Sensory Room, at Larklands, had been converted into an Art Room. All bedrooms had a lockable drawer. Both the bathroom and shower room had locking devices fitted to the outside of the door that could lead to a resident, or staff member, being locked in the room. The provision of a device on the inside of the door, such as a lever, was discussed with the Deputy Manager. Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 18 The Home had a comprehensive Infection Control policy and a new member of staff was well able to describe the process of transporting infected material within the Home and its disposal. There was a sluicing sink in the laundry room as well as a washing machine and dryer. Of the five bedrooms in Larklands, two were carpeted and three had laminated floors to enable easy cleaning. The Home was clean and hygienic with no offensive odours. Larklands And Church View DS0000002171.V297877.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 & 35 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents were being supported by a qualified and skilled staff group of adequate numbers. They were being fully protected by the Home’s staff recruitment practices. EVIDENCE: There was a good range of skills, knowledge and experience within the staff group to help residents with care and support and this was observed being put into practice during the inspection. The Manager confirmed that 56 of care staff had completed a National Vocational Qualification (NVQ) to level 2 or above. Staffing levels were high to reflect the high dependency needs of the resident group. The Deputy Manager said that there was one nurse over establishment within the Home. Two new members of care staff were due to start in July 2006 and this would bring the staff group to full establishment. Records confirmed that two members of agency staff had provided eleven social care worker night shifts over an eleven-week period prior to this inspection. The Manager stated that these had been cover for long term care staff sickness. The staff rota indicated that a number of staff were working long hours – 56 over 8 consecutive days in the case of one social care worker. The Manager Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 20 stated that this was at the staff member’s request and agreed that several staff had 48-hour weekly contracts. He added that the Home was looking at ways of reducing staff hours by appointing more staff and that when staff work long hours then outside activities are built in. It was noted that there was a good mix of part time and full time staff, giving flexibility as well as consistency. The files of the case-tracked residents provided evidence of explicitly different staffing ratios depending on the activities undertaken and the degree of risk involved. For instance, a 2:1 ratio was provided during swimming. This was good risk management. The file of one very recently appointed member of care staff was examined and all information and documents required by Regulation had been obtained prior to appointment. The Home was awaiting a Criminal Records Bureau (CRB) disclosure on this staff member and meanwhile she was shadowing other staff. The Induction Record of this new member of staff was examined and was appropriately completed. The Record was to Skills for Care standards although, the Manager reported, the Learning Disability Awards Framework (LDAF) was not being used due to difficulty finding suitable material. This was accepted. The Manager stated that staff work a three-month probationary period before being put forward for NVQ level 2 training. The Home had developed a ‘training matrix’ providing an at-a-glance view of staff training undertaken and needed. This showed that the majority of staff had undertaken mandatory training – the main need was now for Adult Protection training. The Manager, Deputy Manager and one other nurse each had a professional training certificate, the Manager stated, and would be providing staff with training on topics such as diabetes, epilepsy and autistic spectrum disorders. At least four staff had completed an external training course on ‘Intensive Interaction’ – which is designed to improve residents’ behaviour and their personal relationships. Larklands And Church View DS0000002171.V297877.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents were benefiting from a well run Home where quality monitoring was in place. Their health, safety and welfare was being protected. EVIDENCE: The Manager had worked at the Home since August 2003 and been Manager since February 2004. He qualified (RNMH) in 1994 and completed his NVQ level 4 in management in March 2006. This had been internally verified and he was currently awaiting the results of an externally verification. The Company have a quality monitoring system based on monthly audits by the Home’s line manager and one of these reports was examined at this inspection. An Annual Plan had been developed for the Home and this was examined. It covered a useful range of topics but still did not indicate any timescales for achievement. One aim was to tackle “Quality issues within the Home”. Questionnaires had been sent to relatives immediately after the last Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 22 inspection. The completed questionnaires were examined and all were found to be positive. Accident records were examined showing good practice being followed. The completed pre-inspection questionnaire indicated that Health and Safety checks, and equipment maintenance, were being carried out at appropriate intervals. A recent Portable Appliance Test (PAT) label was seen on an item of electrical equipment in the office. A brief discussion with the member of domestic staff in Churchview showed that he did not know where the cleaning materials Product Data Sheets were kept. This was concerning. There were no other Health & Safety concerns at this inspection. Larklands And Church View DS0000002171.V297877.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 3 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 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Larklands And Church View DS0000002171.V297877.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 Timescale for action 01/08/06 2. YA20 13(2) 3. YA24 13(4)(a) A written protocol, on the use of ‘prn’ - as and when required – medication, must be provided in respect of all residents who have this medication. These protocols must be explicit and, preferably, include examples to minimise different interpretations. The recording of the 01/08/06 administration of prn medication on MAR sheets must be clear and consistent. The bathroom and shower room 01/08/06 doors must be provided with internal devices that would prevent a resident, or staff member, being locked in the room. 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. Refer to Standard YA6 Good Practice Recommendations Residents’ social needs should be recorded within Action DS0000002171.V297877.R01.S.doc Version 5.2 Page 25 Larklands And Church View 2. YA18 3. 4. 5. 6. 7. 8. YA20 YA22 YA23 YA33 YA39 YA42 Plans. Their likes and dislikes should also be recorded. Photographs, or other means, should be considered as a pictorial representation of food - to further enable residents to make choices and decisions about what they eat. A general written policy on the use of prn medication should provided. There should be a paper recording system, in the Home, for complaints received. Adult Protection training to staff should be provided as planned. The Home should carry out its plans to consider ways of reducing the long hours worked by some staff. The Annual Plan should indicate timescales for achievement. All staff should be reminded where the cleaning materials Product Data Sheets are kept. Larklands And Church View DS0000002171.V297877.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Larklands And Church View DS0000002171.V297877.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. 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