Inspection on 18/01/07 for Midway (5)

This inspection was carried out on 18th January 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Midway (5) 12/09/05

Midway (5) 07/06/05

Midway (5) 06/09/04

Midway (5) 17/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Midway (5) 5 Midway Walton- on-Thames Surrey KT12 3HY Lead Inspector Damian Griffiths Unannounced Inspection 18th January 10:00 Midway (5) DS0000013512.V325406.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 Midway (5) DS0000013512.V325406.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. Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Midway (5) Address 5 Midway Walton- on-Thames Surrey KT12 3HY 01932 253501 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) Welmede Housing Association Ltd Mrs Marie Denise Farouk Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 35-64 YEARS 12th September 2005 Date of last inspection Brief Description of the Service: Midway is a care home for 6 adults with learning disabilities, and is located on a private road within walking distance of Walton-on-Thames town centre. The home is a large detached house with a parking area to the front of the building and a large secluded garden to the rear. All bedrooms are single occupancy and there are bathroom and toilet facilities on each floor. On the ground floor there is a large sitting room, a separate dining room a large fitted kitchen, and a well equipped utility room. Midway provides homely and comfortable accommodation for the residents. Welmede Housing Association is the registered proprietor of the home and the staff are employed by the North Surrey Primary Care Trust. Cost per week £1226 Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the Commission for Social Care Inspection (CSCI) year April 2006 to 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. The registered Manager Denise Farouk representing the establishment assisted Regulation Inspector Damian Griffiths throughout the inspection. The IBL process involves a pre-inspection assessment of service information from a variety of sources initially helping to prioritise the order of inspections and identify areas that require more attention during the inspection process. A new Inspection record is compiled from details received from a preinspection questionnaire, notifications of significant events known as Regulation 37’s compiled by the home. Any comments and complaints received and previous inspection reports are all considered for inclusion prior to the inspection visit. For more details of ‘IBL’ please visit the Commission for Social Care Website details can be found on the last page of this Inspection report. The inspector was with staff and service users at 5 Midway for a period of 7 hrs. The care needs of the service users at the home were complex and demanding and staff were required to be competent communicators. The inspector ensured that time was spent sampling service user’s care need assessments, care plans, and talking to service users and observing interaction between service users and staff. Staff files were inspected for evidence of good practice in the following areas: recruitment, training and the distribution of staff skills compiled in the daily rota. A relative complimenting the home stated: ‘everybody is happy’ at the home. The inspector would like to extend thanks to the residents, their relatives, management and staff at 5 Midway for their time and hospitality. What the service does well: The home had used the Welmede ‘Moving in’ policy for new service users interested in moving into a Welmede home, potential new service users could visit a number of times and meet the services users and if appropriate a full assessment of care need would be arranged. Service users were provided with a homely environment that was clean and tidy and enjoyed comfortable and individualised bedrooms and communal areas and enjoyed a varied diet that included daily fresh fruit and vegetables purchased by the service users at the local supermarket. Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 6 The Management and staff team were working well together and had obtained skills and qualifications to ensure a safe, well run, and homely environment was maintained for the service users. Care plans were consistent and contained details of service users preferences, good risk assessments and general details required for the delivery of care. Residents benefited from good links with the neighbourhood and the community and enjoyed the activities provided at the home. Choices representing individual lifestyle were respected and staff supported service users to maintain contact with their family and friends. The service users benefited from good links with health care providers in their local area and in the way they wished to receive that support. The medication administration protocols at the home were good and enabled the service users to receive their medicinal care safely on a daily basis. The homes safeguarding vulnerable adults procedures was in place and staff had received training. What has improved since the last inspection? What they could do better: Standards were only partially met in four areas and the registered manager was required to: Ensure that incidents are properly recorded including complaints and that they are included in the current complaints book. That the entrance hall, dining room office and all other parts of the home are redecorated. This was the second time this requirement had been made. That when recruiting, employees provide all the required documentation specified by regulation and in particular; A full employment history, together with satisfactory written explanation of any gaps in employment’. Six ‘good practice recommendations’ were made in the following areas: That the home considers purchasing it’s own digital camera. That the home considers placing risk assessments in one section of the care plan file. That the direction for taking prescribed medication was made clearer, ‘as directed by GP’ does not provide sufficient detail. Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 7 That staff pay particular attention to the Surrey Multi-Agency Procedures for the Safeguarding of Vulnerable Adults and Welmede’s whistle blowing policy. That the manager produces an annual ‘aims and objectives’ plan for the attention of CSCI and that the Welmede housing association provides a new tumble dyer as soon as possible. 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. Midway (5) DS0000013512.V325406.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 Midway (5) DS0000013512.V325406.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): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Useful information about the home and local area was available in a form that was relevant and understandable to service users and relatives. All files sampled contained evidence of assessment of care need. EVIDENCE: The Statement of Purpose and Service User Guide had been produced with service users in mind. A photo of the service users either engaged in a particular task or showing a particular place in the local area favoured by service users accompanied each section of the information booklets. Local places of interest had recently been redeveloped and offered new photo opportunities for updating the service users guide however the home does not own its own camera and relied on the good will of the staff to provide one. It was recommend that the home consider purchasing it’s own digital camera. The home had used the Welmede ‘Moving in’ policy for new service users interested in moving into a Welmede home, potential new service users would be expected to visit the home a number of times and meet the resident services users and if appropriate a full assessment of care need would be arranged. Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 10 Service users care plans showed evidence of comprehensive assessments being completed. Please see the recommendations section of this report. Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were consistent and contained details of service users preference, good risk assessments and good general details required for the delivery of care, however some areas of the care plan were not well organised. EVIDENCE: Service users were involved in the planning of their care plans, which accurately reflected care needs. Care plans were regularly re-assessed and reflected changing needs and personal goals covering a wide variety of areas including: Hospital admission plan, likes and dislikes, action plans and activities. Staff had assessed the service users preferred method of care assistance. Care plan folders contained a ‘likes and dislikes’ section that ensured care workers had a record of service users preference and choice, especially service users who had difficulty communicating. Staff were observed responding in a way that was preferred by the service user and as stated on the care plan. This approach had been appropriately extended to include risk assessments used to support an Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 12 independent lifestyle relative to care need. Examples of risk assessments were found in different areas of the care plan folders such as the: risk of choking was noted on a ‘evaluation sheet’ and additional risk assessments were found under ‘assessments’ and ‘action plans’ that may have been better placed in the risk assessment section of the care plan, therefore it was recommended that the home consider placing risk assessments in one section of the care plan file. Please see the recommendations section of this report. Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefited from a good links within their neighbours and community and enjoyed the activities provided at the home. Service users individual lifestyles were respected and staff supported service users to maintain links with their family. Service users enjoyed a choice of meals that included fresh fruit and vegetables purchased by the service users at the local supermarket. EVIDENCE: Service users could access the local facilities for adult education as appropriate but most service users benefited from attending a specialist centre were they could gain assisted work experience. Evidence of service users attending yoga and a music workshop were observed. It was reported that the neighbours lent support in overseeing service user safety and were very supportive, often taking in mail or packages left for the Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 14 home. Access to the local area features in both the service users guide and the statement of purpose, community venues familiar to the service users such as visits to shops, cinema and leisure centre. Reference to family links and support could be found in service users care plans. A recent service users birthday had elicited praise from the family who had written to the home thanking them for all the arrangements they had made and going on to state that: staff ‘were devoted’. Service users’ rights were respected and were observed by the inspector throughout the day. A very happy service user enjoyed showing me her room, new shoes and clothes recently bought. This service user enjoyed shopping and evidence of a well managed personal bank account was in place. Service users were observed access to the entire house observed freely moving around, watching TV and entertaining themselves. Care was taken to ensure that service users diets were appropriate and provided fresh fruit and vegetables daily. A care plan recorded how staff were to encourage service users to eat healthily. Service users were observed helping themselves to drinks. Menus were provided and the home had access to a pictorial menu-planning guide to assist the service users. Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users benefited from good links to health care providers in their local area and the way the wished to receive healthcare support. The medication administration protocols at the home were good and enabled the service users to receive their medicinal care, safely on a daily basis. EVIDENCE: Staff had assessed the service users preferred method of care assistance. Care plan folders contained a ‘likes and dislikes’ section that ensured care workers had a record of service users preference and choice, especially service users who had difficulty communicating. Staff were observed responding in a way that was preferred by the service user using speech and body language as appropriate. Makaton was not used, as service users preferred their own form of communication. Service users required assistance to manager their health care requirements and it was evidenced that specific information about each service user was in place. Nearby local health care practitioners were regularly involved with the service users care needs. Service users had participated to create an Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 16 accurate record of what help and support was needed and protocols to be followed. The home provided daily support to service users requiring regular medication, therefore, the homes Medicines Administration Records were inspected. The medicine cabinets were of the appropriate design but were currently too small to hold a monthly supply of medication due to the introduction of the ‘pre-packed ‘blister’ system of prescribing. The home had ordered larger cabinet and currently collected prescriptions on a weekly basis. The home had a good relationship with the health care practitioners and had reviewed service users medication following a series of falls. Medicines Administration Records were in good order however it was recommended that the direction for taking prescribed medication is made clearer and ‘as directed by GP’ provided insufficient detail. Please see the recommendations section of this report. Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes complaint and compliments policy was in place and there had been one complaint made against the home however there was no record of this available for inspection. The homes safeguarding vulnerable adults procedures were in place and staff had received training. EVIDENCE: The home’s complaint book showed no evidence of complaints received and policy and procedures were in place and could be found in the statement of purpose and service users guide. There was one complaint that had not been recorded adequately by the home due to the complaint being dealt by Welmede’s head office. Compliments and letters of thanks had been sent. Comments received included: ‘Devoted staff’ referring to consistently good work helping service users when visiting their family. Thanks were given in appreciation of these visits and comments about ‘everybody being happy’, at the home. The home possed a new DVD player that had been bought following the receipt of the Surrey Multi-Agency Procedures to Safeguard Vulnerable Adults and an in-house training session was planned for staff viewing the DVD. Staff received periodic training in this area. There had been no reported incidents in relation to the safeguarding of vulnerable adults. Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 18 The home regularly notified CSCI of incidents affecting the wellbeing of service users as required under Regulation 37 of the Care Homes Regulations (2001 Amended). Outcomes of the reports were inspected and were shown to be in order. It was recommended that staff pay particular attention to the Surrey procedures and Welmede’s whistle blowing policy. Please see the requirements and recommendations section of this report. Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users were provided with a homely environment that was clean and tidy and enjoyed comfortable and individualised bedrooms and communal areas however the standard of decoration and maintainence only partially met the National Minimum Standards. EVIDENCE: A tour of the premises revealed a home that was clean, comfortable, showing signs of normal ‘wear and tear’ and in need of routine maintenance and regular decoration. Areas identified in the last inspection report included: The entrance hall, dining room and office that were in need of redecoration. This situation extended to most of the home however this did tend to make the home feel more homely. Service users were comfortably seated in the living room that had received a face-lift and new curtains had been provided. The condition of the ground Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 20 floor bathroom was now, excellent and equipped with a new bath and hoist system. A service user gave a detailed tour of the premises including their own bedroom that was spotless and tastefully decorated to the service users delight. Due to the high winds experienced at the time of the inspection windows had been blown wide open revealing a lack of secure window restrictors. The communal bathroom upstairs suffered from excessive peeling of paint to the ceiling and walls. The home operated a discreet laundry system that was observed to be working well and service users were dressed well. Staff had worked hard to ensure that, despite the lack of a workable ‘tumble dryer’ service users were well cared for. The laundry area was clean and accommodated hand washing facilities. Please see the requirements and recommendations section of this report. Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 21 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 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users benefit from being cared for by staff that understands their care needs and who were well trained however the recruitment requirements had not been fully met. EVIDENCE: The staff were from diverse backgrounds and ethnicity and worked very well together being able to respond to service users individual needs. The staff team work in shifts of early or late and there are three people on duty except at night when there is a member of staff on waking night duty. It is commendable that the home covers all absences from a bank of their own staff and do not employ agency staff. Three staff files were sampled for details of the homes recruitment practice. All staff had received a positive a criminal record check and application forms, job descriptions, contracts and references were in evidence however all three had incomplete employment histories. Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 22 Staff on duty were well qualified and the skill mix ensured the well-being and needs of the service users was being met. Training included: Core training such as: manual handling, food hygiene, health and safety and safeguarding vulnerable adults. Staff consulted said that they enjoyed working at the home and had no problems working additional shifts when cover was needed. Please see the requirements section of this report. Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 23 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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and staff team were working well together and had obtained skills and qualifications to ensure a safe, well run, and homely environment was sustained for the service users however the home failed to give service users, their representatives and staff connected to the home the opportunity to contribute to a quality assurance exercise. EVIDENCE: The Manager operated an open door policy and staff and service users were welcome to visit the office and as observed during the inspection would feel at ease to sit and talk about their interests or just sit quietly. Staff worked well with the manager however the deputy manager had recently left and the manager was planning to retire. Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 24 It is recommended that the manager produce an annual ‘aims and objectives’ plan for the attention of CSCI. The home had not produced an assessment of the quality of care at the home since 2005, however, Welmede managers complete monthly inspections of each others homes and copies of these reports are made available to the inspector at the local CSCI office. Residents meetings were also held every month. Minutes made available to the inspector revealed that discussions were held about the Xmas dinner and what presents service users would like. Other information recorded what holidays were being planned, such as a stay in Devon and trips out to Pub. Health and safety check lists were allocated to staff to ensure that daily checks were made and a current Environmental Health Certificate was in place. The lack of a working tumble dryer and indoors drying facilities had caused a minor health and safety problem at the home. It was recommended that the Welmede housing association provide a new tumble dyer as soon as possible. Please see the recommendations section of this report. Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 25 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 3 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 26 YES 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 YA22 Regulation 17 (2) Para’ 11 Schedule 4. Requirement The registered manager must ensure that any incident is properly recorded including complaints and they are included in the current complaints book that is available for inspection by CSCI. Details must be sent to the CSCI within the given timescale. The entrance hall, dining room, first floor bathroom and office are in need of redecoration. This was the second time this requirement was made. An action plan must be submitted to CSCI giving details of the redecoration schedule. The registered manager must only employ a person to work at the home subject to receiving documents specified in paragraphs 1 to 9 of schedule 2 In particular paragraph 6 that states that; A full employment history, together with satisfactory written explanation of any gaps in employment’ The registered manager must make arrangements to enable staff to inform the registered DS0000013512.V325406.R01.S.doc Timescale for action 18/02/07 2. YA24 23(2)(b) 18/02/07 3. YA34 19 (1)(b) 18/02/07 4. YA39 21 (1)(2) 18/04/07 Midway (5) Version 5.2 Page 27 person and CSCI of their views and those of the service user and their representatives about any matter to which this regulation applies. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 5. 6. Refer to Standard YA1 YA9 YA20 YA23 YA37 YA42 Good Practice Recommendations It was recommend that the home consider purchasing it’s own digital camera. It was recommended that the home consider placing risk assessments in one section of the care plan file. It was recommended that the direction for taking prescribed medication was made clearer and ‘as directed by GP’ provided insufficient detail. It was recommended that staff pay particular attention to the Surrey safeguarding vulnerable adult procedures and Welmede’s whistle blowing policy. It is recommended that the manager produce an annual ‘aims and objectives’ plan for the attention of CSCI. It was recommended that the Welmede housing association provide a new tumble dyer as soon as possible Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Midway (5) DS0000013512.V325406.R01.S.doc Version 5.2 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. 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