Inspection on 29/07/05 for Lee Road (9-11)

This inspection was carried out on 29th July 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lee Road (9-11) 27/02/09

Lee Road (9-11) 25/06/07

Lee Road (9-11) 05/04/06

Lee Road (9-11) 16/01/06

Lee Road (9-11) 17/03/05

Lee Road (9-11) 12/08/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Lee Road (9-11) Southcourt Aylesbury Bucks HP21 8JF Lead Inspector Nichola Cahill Gill Gentles Announced 29th July 2005 9:30am 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 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 Stationary 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. Lee Road (9-11) Version 1.10 Page 3 SERVICE INFORMATION Name of service Lee Road (9-11) Address Southcourt, Aylesbury, Bucks, HP21 8JF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01296 483997 Royal Mencap Society Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (0) of places Lee Road (9-11) Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th March 2005 Brief Description of the Service: 9-11 Lee Road is registered for the care of 6 service users with a learning disability. The home was originally two houses, which have been knocked into one for the purpose of providing care.The building is leased from the council and is managed by MENCAP. It is situated on a busy estate in the heart of Aylesbury and is a short bus ride away from the town centre.All bedrooms are single with one providing en-suite facilities. There is a lounge and a dining area that are adequately sized for the numbers of service users for which the home is registered. A homely domestic environment is provided.A large, well maintained garden is available for the enjoyment of service users and visitors to the home. The home has ramped access with grab rails to the front and rear. The home has easy access to community facilities, including GP surgeries, shops, pubs, a library and leisure facilities. Lee Road (9-11) Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the summary of the annual announced inspection visit carried out on 29th July 2005 by Nicky Cahill (lead inspector) and Gill Gentles (inspector). The inspection visit was carried out over a period of seven hours with a follow up visit being made on 12th August 2005. The inspection visit consisted of meeting with service users, staff and the acting manager, Jerry Hearn. Documentation was viewed pertinent to the health and well being of service users, staff recruitment, the day-to-day running of the home and health and safety. Prior to the inspection The Commission received feedback questionnaires from all service users and a small number of other stakeholders. What the service does well: What has improved since the last inspection? Service users were involved in regular meetings to ensure that they were consulted with regard to the decisions made within the home. The acting manager had instigated such meetings since his secondment. Documentary Lee Road (9-11) Version 1.10 Page 6 evidence was available. Service users confirmed that they are supported by the homes staff in making choices. The systems in place for the storage and safe handling and administration of medications were viewed during the inspection visit. A new cabinet has been placed in the homes office since the last inspection visit. An MDS system is in place, which has been provided by a reputable chemist. A comprehensive policy is in place and information is retained for each medication prescribed. A medication returns book is in place and duly signed. A permanent manager is now in post and has made some positive changes since his secondment began in March 2005. What they could do better: Service users must be provided with information regarding the services offered by the home. Information must be presented in a format suited to their individual needs. The home must ensure that the assessed needs of service users are fully met. Information recorded in care plans must be up to date and written in consultation with service users. All information must be stored in accordance with The Data Protection Act 1998 and must protect the privacy of service users. The organisation must ensure that the home is maintained to a good standard and that all health and safety issues are addressed. They must ensure that equipment is provided for service users to ensure that their needs can be fully met. The home does not have a sufficient number of staff on duty at any one time, this does not ensure that the current and ongoing needs of the service user group are met. The homes current recruitment practices do not provide assurance that the safety of service users is promoted at all times. Staff training is lacking in some areas. This does not ensure that staff fulfil the aims of the home and meet the changing needs of service users. Lee Road (9-11) Version 1.10 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Lee Road (9-11) Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Lee Road (9-11) Version 1.10 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 standard(s) 1, 3, 5. The home has a statement of purpose and service users guide. Both documents were in need of a review with some information being out of date. The service user guide is not written in a format suited to the needs of the service users. Service users are not equipped with up to date information regarding the services offered at the home. The home are currently unable to fully meet the needs of one aging service user due to their failure to implement advise from an external healthcare professional. This is at the detriment of the health and well being of this service user. All service users are issued with terms and conditions of residency and a contract detailing payments to be made. Service users or a representative have information to ensure that they are aware of the charges for the individual services received. EVIDENCE: The statement of purpose and service user guide was viewed as part of the pre-inspection preparation. The statement of purpose required some amendments to the name and qualifications of the manager and existing service users names must be removed from the information regarding the number and size of rooms at Lee Road. Lee Road (9-11) Version 1.10 Page 10 The service users guide must be amended to ensure that it is written with the individual service users abilities in mind. It is a requirement that the statement of purpose and service user guide are reviewed and amended accordingly. One concern noted was that an elderly service user who has lived in the home for many years was not able to use equipment and move around the home freely due to insufficient aids and adaptations. An occupational therapy assessment had been carried out, however, no action had been taken to meet any recommendations made. A further visit had been made to the home and reference was made to such unmet recommendations. Another concern was that this gentleman had a showering facility that had been installed specifically for his use and at his own expense. MENCAP had failed to make repairs to this facility for several years and consequently this shower had continued to be out of order. Correspondence was viewed on file to evidence this. It is a requirement that the organisation ensure that the on-going needs of service users are met and that adaptations and other aids are fitted according to the recommendations of other healthcare professionals. It was noted from correspondence viewed that the acting manager had secured the services of a plumber to repair the shower currently out of order. Since the inspection The Commission have been notified in writing that this work is now complete. Service users contracts and terms and conditions of residency were viewed. These appeared to be in order. Lee Road (9-11) Version 1.10 Page 11 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 standard(s) 6, 7, 8, 9, 10. All service users have a plan of care. Some information was not up to date and did not identify the current and ongoing needs of the service user. Service users are assisted in making choices and life decisions and participate in all aspects of life in the home. Service users are supported in taking risks. However, these areas are not always evidenced within care plans. Information recorded would not enable staff to fully support and meet the needs of the current service user group. Staff appeared to be respectful when dealing with service user information, however, current documentation pertinent to individual service users is easily accessible in the homes main office. The privacy of service users confidential information is compromised. EVIDENCE: Three care plans were viewed during this inspection visit. Service users essential information and next of kin details appeared to be up to date, however, other information was extremely out of date. For example, one daily living skills assessment was dated 29.07.03. It was also noted that one service user had been diagnosed with a serious ailment, this was not mentioned in the appropriate documentation and appeared only briefly in section 8 of the care Lee Road (9-11) Version 1.10 Page 12 plan. Individual goal setting had not been completed, one service user had one identified goal which was wholly inappropriate. Risk assessments had been recently reviewed and contained relevant information. It was clear that medical appointments had been accessed for service users and support given to attend. It is a requirement that all care plans are reviewed and updated in consultation with individual service users. Care plan information should include details of all aspects of service users social, health and welfare needs and must indicate how support will be given in order for such needs to be met. Service users were involved in regular meetings to ensure that they were consulted with regard to the decisions made within the home. The acting manager had instigated such meetings since his secondment. Documentary evidence was available. Service users confirmed that they are supported by the homes staff in making choices. It was noted that all service user files were stored in the homes ground floor office, this did not appear to be locked when unattended. The acting manager is reminded that all information must be stored in accordance with The Data Protection Act 1998 and service users privacy protected at all times. Lee Road (9-11) Version 1.10 Page 13 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 standard(s) 15, 16. 11, 12, 13, 14, Service users are supported in their interests and hobbies and have access to the local community. Service users rights are protected. EVIDENCE: Service users have at least one ‘home day’ per week. This is spent with a member of staff who will support the service user in maintaining their life skills. All service users go to day centres most days and two also go to thrift farm where they do paid work. The home has an ageing service user group who are happy to relax and enjoy day centres and leisure activities. Lee Road (9-11) Version 1.10 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 Service users are supported by care staff who are very aware of their physical and emotional needs. However, the lack of regard for recommendations made by other health care professionals to further support individual needs has affected the health and well being of service users. Medication needs are supervised by the acting manager and care staff. Service users are fully supported in the administration of all medications and are safeguarded against any risks to their safety. EVIDENCE: Staff appear to be very aware of the service users current and ongoing needs and are able to support service users in accessing external resources. However, as previously discussed within this report, the organisation have not facilitated recommendations made to further improve the health and well being of one service user. It would appear that this has had an effect on other service users who have been residing together for many years. A requirement has been made previously within this report. The systems in place for the storage and safe handling and administration of medications were viewed during the inspection visit. A new cabinet has been placed in the homes office since the last inspection visit. An MDS system is in place, which has been provided by a reputable chemist. A comprehensive Lee Road (9-11) Version 1.10 Page 15 policy is in place and information is retained for each medication prescribed. A medication returns book is in place and duly signed. It is recommended that a PRN protocol be in place, that GP consent is obtained for the administration of homely remedies to individual service users and that creams and ointments are dated as opened. Lee Road (9-11) Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 A comprehensive complaints procedure is in place. This allows the service user to air their complaints and concerns regarding the day to day running of the home. EVIDENCE: A comprehensive complaints procedure is in place and service users appeared to be empowered in airing their concerns and complaints. The complaints file was viewed during the inspection, two complaints had been logged. It was discussed with the acting manager that due to the nature of one of these complaints storage in this file would be inappropriate. This document was removed at the time of this inspection visit. Lee Road (9-11) Version 1.10 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 standard(s) 24, 25, 26, 27, 28, 29. The homes premises are suitable for their stated purpose. The layout and location of the home meets with the needs of the service users. Service users all have single bedrooms, which are suited to their own specific tastes. However, the location of bedroom areas is not suitable for all service users due to the lack of aids and adaptations ensuring safe access to the second floor of the home. Service users have access to a number of bathing and toileting facilities. However, these are in bad repair and are not suited to the individual needs of all service users. The home has adequate shared space. However, communal areas are not well maintained and do not provide service users with a homely comfortable area to socialize. The home is equipped with ramped access and a grab rail. Internally, the home is not fitted with specialist equipment suited to the needs of service users. EVIDENCE: Lee Road (9-11) Version 1.10 Page 18 The home is situated on a busy estate in the heart of Aylesbury. The council owns the house and The Commission have been made aware that there have been issues around the responsibility of the up keep of the building. It was discussed during inspection with the acting manager that it is the responsibility of MENCAP as the care providers to ensure that the home is maintained to an acceptable standard of décor and that all health and safety issues have been addressed. During the previous two inspection visits a requirement has been made for the home to install window restrictors to the upstairs areas of the home. This requirement had still not been met. An immediate requirement was issued that this work be completed by 14th August 2005. The Commission has since received written confirmation that this work is now complete. All service users have single bedroom accommodation; one bedroom is on the ground floor of the home. It was noted from documentation and discussions with the acting manager that an upstairs bedroom for one service user had become impractical due to the lack of adaptations made to the home. This has been discussed previously within this report. Bedrooms were very reflective of the individual service users and were full of personal items and pictures. The home has one ground floor bedroom fitted with a showering facility, there is also a ground floor bath and toilet available. On the first floor an assisted shower has been fitted for the use of one service user. The up keep of this bathing facility has been discussed previously within this report. The home has a lounge and separate dining area for service users use. A large garden is also available for service users and is accessible via a ramp and grab rail. It was noted during the inspection visit that the communal areas and all corridors were badly in need of redecoration and refurbishment. Wall paper in the lounge area had not been changed for a number of years and was worn and peeling. The lounge needed redecorating and the furnishings were looking very worn. Corridors had received a bland coating of white paint by one of the homes volunteers. Bathing areas and bedrooms were also in need of some redecoration. It is a requirement that the organisation provide a rolling programme of redecoration and refurbishment for the home. This programme must indicate that all works will be complete by the given timescale and must be forwarded to The Commission for monitoring purposes. It has been discussed during the previous two inspection visits that the service user group are aging and that their needs are rapidly changing. Due to these Lee Road (9-11) Version 1.10 Page 19 changes the homes environment does not necessarily meet the needs of all service users. A requirement has been made previously within this report that the organisation ensure that the on-going needs of service users are met and that adaptations and other aids are fitted according to the recommendations of other healthcare professionals. Lee Road (9-11) Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 The home does not have a sufficient number of staff on duty at any one time, this does not ensure that the current and ongoing needs of the current service user group are met. The homes current recruitment practices do not provide assurance that the safety of service users is promoted at all times. Staff training is lacking in some areas. This does not ensure that staff fulfil the aims of the home and meet the changing needs of service users. EVIDENCE: The home is currently staffed by two staff during the waking day and one sleep in at night. Staff alternate the cover of sleep in night duties, staff are not often disturbed during the night. The home has had a big turnover of staff during the last eighteen-month period. It would appear at the time of this inspection visit that the home now has a core group of permanent staff. Use of agency staff is now rare. From discussions with the acting manager, staff and service users it was indicated that service users needs are not being met as assessed due to the limited number of staff available during the day. There have been difficulties in ensuring that service users are allowed adequate time for assistance with personal care and to access external facilities due to their growing needs. Lee Road (9-11) Version 1.10 Page 21 It is a requirement that the organisation review the numbers of staff allocated on each shift to ensure that the current and ongoing needs of service users are appropriately met. It has been noted during previous inspection visits that staff recruited through 9-11 Lee Road were providing care support for a supported living complex also belonging to MENCAP. It has also been noted that any manager in post at Lee Road is required to supervise the staffing of this other unregistered supported living service. This had been discussed and concerns aired that the staffing for any other establishment should be addressed separately from this registered service. Feedback from the acting manager indicated that there was still no date discussed by the organisation for this practice to cease. It is a requirement that the organisation ensure that the staffing of 9-11 Lee Road is not compromised by the support for other services not registered with The Commission. Alternative arrangements must be made for the management of other services. Recruitment files were viewed during the inspection visit. Documentation required under The Care Homes Regulations 2001, Schedules 2 and 4 was not available in all files viewed. Documentation was not available for two relief staff employed through MENCAP. It is a requirement that recruitment practices comply The Care Homes Regulations 2001, Schedule 2 and 4, this must be in place for all staff working in the home. The training matrix for all staff employed at 9-11 Lee Road was viewed. This shows that only 50 of staff have received training in fire safety, 1 member of staff has received training in manual handling, all have received first aid training and two staff have not received food hygiene training. It was noted that there is no specialist training in place at present, for example, dementia awareness and protection of vulnerable adults. It is a requirement that all staff receive update training in all mandatory areas and any specialist areas pertinent to the assessed needs of service users. Lee Road (9-11) Version 1.10 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41, 42, 43. An acting manager is in post, who has, during the last five months, started to address shortfalls in the day-to-day running of the home. It would appear that service users are beginning to benefit from this pro-active approach. Service users have participated in service user meetings, completed quality audit questionnaires and are well supported by the homes staff. Service users are empowered by the homes staff in making future changes in the home. The homes records are not up to date in all cases. This does not allow the home to run effectively and efficiently and does not safeguard the interests of service users. Health and safety issues have not been addressed as a matter of course and have compromised the safety of service users. EVIDENCE: Lee Road (9-11) Version 1.10 Page 23 The home had been through a period of instability with the registered manager leaving in October 2004. An acting manager, Jerry Hearn, was seconded to the home in March 2005. The Commission expressed concern prior to the inspection visit that the organisation had not recruited a permanent manager for the home during this period. This had proved an uncertain time for staff and service users. It was pleasing to note that at the time of inspection interviews were being carried out for this position and that the acting manager was being considered. The Commission have been notified since the inspection visit that Jerry Hearn will take up the permanent post as manager and will be put forward for his registration with The Commission. Service users had been assisted in completing questionnaires prior to the inspection visit. No specific concerns had been noted. Service users had attended house meetings in April, May and July 2005. The meeting minutes were viewed which showed that discussions had taken place around holidays; day trips and specific needs and wishes of service users. However, documentation did not indicate how such requests would be met. It is recommended that items addressed in consultation with service users during meetings are noted on meeting minutes before distribution to service users. A MENCAP service review had taken place in August 2004. The 2005 review will be viewed at the homes next inspection. The homes records are not up to date in all cases. This has been discussed previously within this report. The following health and safety documentation was viewed; • The fire authority had visited the home on 18.06.04 – requirements had been addressed. In house fire tests had been carried out and recorded appropriately. It is recommended that the fire authority check the fire risk assessment. • A gas safety inspection had been carried out on 29.10.03 – It is a requirement that gas safety inspections are carried out annually. • Fixed wiring had been tested on 20.02.04. • PAT testing had been carried out on 22.03.05. • Accident and incidents had been logged appropriately. • An Environmental Health Inspection had been carried out on 14.06.05. • Other health and safety checks were viewed and appeared to be in order. A requirement made during the previous two inspection visits regarding window restrictors has been discussed previously within this report. The homes annual budget summary was requested for 2003-2004 and was duly forwarded to The Commission. However, this did not highlight the individual budget for the home, for example staffing costs, food, utilities and Lee Road (9-11) Version 1.10 Page 24 training costs for staff. It will be expected that this will be available within the home during the next inspection visit. 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x 2 x 3 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 3 3 3 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 2 1 2 1 x Standard No 11 3 Standard No 31 32 33 Score x x 2 Page 25 Lee Road (9-11) Version 1.10 12 13 14 15 16 17 3 3 3 3 3 3 34 35 36 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x 2 2 x Lee Road (9-11) Version 1.10 Page 26 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 1 Regulation 4 and 5 Requirement It is a requirement that the statement of purpose and service user guide are reviewed and amended accordingly. It is a requirement that the organisation ensure that the ongoing needs of service users are met and that adaptations and other aids are fitted according to the recommendations of other healthcare professionals. It is a requirement that all care plans are reviewed and updated in consultation with individual service users. Care plan information should include details of all aspects of service users social, health and welfare needs and must indicate how support will be given in order for such needs to be met. It is a requirement that the organisation provide a rolling programme of redecoration and refurbishment for the home. This programme must indicate that all works will be complete by the given timescale and must be forwarded to The Commission for monitoring purposes. It is a requirement that the Version 1.10 Timescale for action 30.09.05 2. 3 12 30.09.05 3. 5 15 30.09.05 4. 29 23 31.12.05 5. 33 18 31.11.05 Page 27 Lee Road (9-11) 6. 33 18 7. 34 19 8. 35 18 9. 41 23 organisation review the numbers of staff allocated on each shift to ensure that the current and ongoing needs of service users are appropriately met. It is a requirement that the organisation ensure that the staffing of 9-11 Lee Road is not compromised by the support for other services not registered with The Commission. Alternative arrangements must be made for the management of other services. It is a requirement that recruitment practices comply The Care Homes Regulations 2001, Schedule 2 and 4, this must be in place for all staff working in the home. It is a requirement that all staff receive update training in all mandatory areas and any specialist areas pertinent to the assessed needs of service users. It is a requirement that gas safety inspections are carried out annually. 30.08.05 29.07.05 31.11.05 30.09.05 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 20 Good Practice Recommendations It is recommended that a PRN protocol be in place, that GP consent is obtained for the administration of homely remedies to individual service users and that creams and ointments are dated as opened. It is recommended that items addressed in consultation with service users during meetings are noted on meeting minutes before distribution to service users. 2. 39 Lee Road (9-11) Version 1.10 Page 28 Commission for Social Care Inspection 8 Bell Business Park Smeaton Close Aylesbury Buckinghamshire HP19 8JR 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 Lee Road (9-11) Version 1.10 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!