Inspection on 07/08/06 for Mossmead (15)

This inspection was carried out on 7th August 2006.

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 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mossmead (15) 08/02/06

Mossmead (15) 07/12/05

Mossmead (15) 02/02/05

Mossmead (15) 01/10/04

Mossmead (15) 23/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Mossmead (15) 15 Mossmead Chippenham Wiltshire SN14 0TN Lead Inspector Mrs Jacqui Burvill Unannounced Inspection 7 August 2006 17:20p th Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 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 Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 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. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mossmead (15) Address 15 Mossmead Chippenham Wiltshire SN14 0TN 01249 461587 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) Ordinary Life Project Association Mrs Linda Hunter Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 15 Moss Mead is one of a number of homes run by the Ordinary Life Project Association. This home accommodates four service users who have a learning disability and are aged between 18 and 65 years. There is always at least one member of staff when the service users are at home. This includes nights, when there is sleep in cover. Service users have their own bedrooms, which are well decorated and furnished. One of the bedrooms has an ensuite shower room, with a toilet and hand washbasin. There is a downstairs toilet and hand washbasin. On the first floor there is a communal bathroom and a separate shower room. There is a large lounge and dining room with a separate kitchen and utility room on the ground floor. Access to the first floor is by stairs only. There is an enclosed rear garden, laid to lawn and patio, with a summerhouse. Fees range from £750 per week. Inspection reports are readily available in the home. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place in August 2006. Pre inspection information was requested in May 2006 and three service user surveys and three relative surveys were sent out to the home. All of the surveys were returned. A site visit took place on 16th May 2006 at the OLPA head office to look at staff recruitment records and to discuss new arrangements for the safe storage of these records. There were three site visits to the home; the first took place on 7th August to meet service users at the end of their day; the second visit to look at records took place on 8th August and the third visit to meet with the manager and find some specific records took place on 11th August. One of the service users showed the inspector around the home. Four service users, two staff and the manager were met with. The following records were looked at; care plans, shared action plans, risk assessments, medication, menus, fire safety and other health and safety records, quality assurance and staff training records. What the service does well: Service users benefit from clear care plans that focus on their needs and how they are to be met. Service users also help to devise their own goals through shared action plans, where staff help create objectives to ensure that goals are met for the service users. These may include some specific needs, or activities. Daily records are well written, describing choices and decisions service user have made in an objective way. Service users’ views are regularly obtained through tenant meetings and one to one meetings with their keyworker. They are involved in the home as much as possible. The manager and staff team provide good quality care and accommodation in a homely, clean and comfortable setting. Service users have their own bedroom, one of which has an ensuite and clearly feel that Moss Mead is their home by the way they move around the home and use all parts of it. The manager is well organised and is supported by a consistent staff team. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: There are two continuing requirements. One is related to quality assurance, which is on the way towards being completed, as surveys have been sent out and will be collated by a specific time. The policy and procedure will need to be amended to reflect the way in which the information will be used to assess quality in the home and the service as a whole. The other requirement related to the lack of contracts for service users who were re-assessed some years ago. The contracts have not been agreed and this situation needs to be resolved. It is a continuing recommendation that outside agencies support the medication administration training to enhance the current format. Some staff received adult protection training in 2002 and may benefit from an update of their knowledge and awareness of the reporting procedure and signs and symptoms of abuse. More staff trained at NVQ level 2 would enhance the knowledge within the team and benefit service users further. Risk assessments on self closing doors should be reviewed to ensure that all doors in the home are included. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 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 Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 This standard was not assessed on this occasion, as no new service users have been admitted to the home. Service users do not have a contract issued by the placing authority, but have a licence agreement stating terms and conditions within the home. EVIDENCE: Information relating to the previous requirement regarding contracts was looked at and discussed. Service users who have lived in the home for some time still do not have contracts in place with the placing authority. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users can contribute to their care plans and shared action plans and are involved as much as possible to reflect their needs, descisions and choices. They are supported to take risks as part of an independent lifestyle. EVIDENCE: Service users’ care plans, shared action plans and daily diaries were seen. Each service user has a comprehensive file, containing details of service users needs and how they are to be met. There are records to show that care plans and risk assessments have been reviewed on a regular basis. The care plans include sections on communication, personal care, routines, eating and drinking and contact with friends and families. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 11 There is a shortened version of the care plan, which is easily accessible for relief staff who may work in the home from time to time. This includes a photo of the service user. The shared action plan is a set of goals devised by the staff team and service user. These may include specific activities, or how to support the service user with a particular health care need. Goals have dates set and they are reviewed at regular intervals. Risk assessments are in place and reflect the risks that may affect individual service users, such as bathing independently, or walking with staff. Service users have monthly team meetings with their keyworkers and evidence of this is kept. Daily notes provide clear descriptions of the activities that service users take part in and the choices that they may make during the day. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users have full, interesting and active lives, taking part in appropriate activites and being supported with friends and family relationships. Service users benefit from a healthy diet and balanced approach to meals, which they enjoy. EVIDENCE: Four service users were met with. Three of the service users had been to day care and were met with on their return home. The member of staff on duty helped them settle back into the home, with the offer of a drink and the plans for the evening were discussed. One service user chose to spend time playing a particular game in the summer house, which she clearly enjoyed doing. Other service users took part in different activities, and staff were observed to support service users in a caring and patient manner as they worked out what it was service users wanted. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 13 One service user had been at work all day and spoke to the inspector about her job on her return. There had been an increase in the number of hours worked and the service user liked this, although it was tiring when very hot. Service users have full and active lives, attending day care, college and clubs in the evening several times a week. There are one to one activities, such as a walk with staff, shopping and drives out to places of interest. Service users have really enjoyed being able to go away and use the OLPA caravan and showed the inspector some of the photos. Each service user takes care of their own room and receives staff support in managing this. Service users are encouraged to take part in helping with domestic tasks around the home and like doing so. Service users are supported with family contact and all of the service users have close relationships with their family. There are specific arrangements in place with regard to one service user and clear guidelines for staff to follow. There has been positive feedback from one family about how supportive the staff have been. Service users make a choice about what they would like to eat each day as this depends on time between returning from day care and going out again in the evening. During the first site visit, service users were going to have jacket potatoes and ham salad. The menu record showed a careful, healthy and balanced approach to meals, taking into consideration a particular health need for a service user. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 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 the following standard(s): 18, 19, 20 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users receive personal care, healthcare support and medication in a way that benefits them and promotes their well-being. EVIDENCE: Service users have sections in their files about their healthcare needs. This shows when they have attended appointments and the outcomes and actions that may need to be taken as a result. In one case, the health of a service user has dramatically improved as a result of the proactive approach and close involvement with health care professionals. Staff have received specific training in managing an aspect of healthcare and feel confident in their ability to do this. There is clear guidance in the care plans about how service users like to manage their daily routines and this varies depending on their needs and how independent they are. This is an all female service user group and staff team, so currently, there are no issues to address with a staff member of a different sex providing personal care. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 15 There is clear guidance in place on managing aspects of behaviour and a consistent approach from staff has all but eradicated a particular set of behaviours a service user had according to assessment documents. Staff have received training within the organisation in administering medication. A recommendation from the last inspection that an outside professional should be involved has not been acted on. There is a policy and procedure and records relating to the safe administration of medication were in order. No monitored dose system is used in the home and all medication can be accounted for. Service users have been assessed as not being able to manage their medication and receive staff support with this. A partial medication round was seen during the inspection and was carried out safely and correctly. There is guidance on how to complete checks on blood sugar levels and safe guidance and equipment relating to health and safety and infection control measures. Staff spoken with confirmed the method and approach they used and described how the training they received gave them the skills and confidence to carry out the procedure. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 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 the following standard(s): 22, 23 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users’ views are listened to and acted on. Service users are protected from abuse and self harm by procedures in place and would benefit further if staff received refresher training in this. EVIDENCE: There is a complaints procedure and this includes details of the way to contact the CSCI. There have been no complaints since the last inspection. Three of the four relatives commented in the survey that they were aware of the home’s complaints procedure and that they had never had to make a complaint. In one of the care review minute meetings, a letter of thanks to the home from a relative was referred to. This letter was seen during the inspection. It showed how supportive the family found staff to be a year on from admission and how much living in 15 Moss Mead had changed their relative’s life for the better, due to staff dedication. One relative commented in the survey that they are more than happy with the care their relative receives at Moss Mead. Service users are encouraged to talk about the things they would like to do and during the inspection, there was a period of observation, where the staff Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 17 member was working closely with a service user in determining what they would like to do. There are monthly meetings with all of the service user and questions are asked using a certain format. Questions include ‘how are you?, ‘are you enjoying living at 15 Moss Mead’, ‘do you like the food’ and asking for ideas for activities or trips out. Each individual response is recorded. There are policies and procedures that protect adults from abuse and refer to the Swindon and Wiltshire ‘No Secrets’ guidance. Staff had received adult protection training from within the organisation. Some staff received this training in 2002 and would benefit from an update. After the last inspection there was one referral to the Vulnerable Adult Unit. This was resolved satisfactorily and there have been no further referrals necessary. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 30 Quality in this outcome area was excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from a safe, comforable and clean home, where they feel relaxed and at ease. EVIDENCE: 15 Moss Mead is a semi detached house in a quiet and well maintained residential area on the outskirts of Chippenham. There is level access to the front and rear of the home and some space for parking in front of the house. The home is comfortable and maintained to a high standard, with service users having been involved in choices of colours and furnishings in the past. There is a ground floor cloakroom and hand washbasin, next to a ground floor bedroom. This room reflects the choices and interests of the service user and furniture had been rearranged since the last inspection to make better use of the space and to enable the service user to sit in comfort when taking part in one of their favourite activities. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 19 There is a large comfortable sitting room, tastefully decorated and furnished. This leads into a dining room, with table and chairs and a dresser for storage. The kitchen has a separate utility room, with a washing machine and tumble dryer. A recent fire in this room was well contained by staff actions and there are now appropriate risk assessments in place to ensure that the cause of the fire, which was highly unusual, does not occur again. Further detail about this can be found in standard 42. The garden is laid to lawn and there is a summerhouse with seating. This has provided an attractive place to sit and relax and service users enjoy using this very much. On the first floor, there are three bedrooms, one with an ensuite bathroom. Each service users’ bedroom is individually decorated and reflects their tastes and interests. There is a communal bathroom and a separate shower. One of the service users showed the inspector around the home and commented that they liked having a shower in the evening. There is a staff sleep in room on this floor. Service users are positively encouraged to think of Moss Mead as their own home, and on each occasion that the inspector visited the home during the inspection, the door was opened by service users. Service users have a key to their own home and a lockable space. The home was very clean and tidy on the day of inspection and smelled fresh. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from a staff team who have sufficent knowledge about their needs and particular conditions, but would benefit further from a team who had National Vocational Qualifications at level 2. Service users are protected by a robust recruitment procedure. EVIDENCE: There is always one staff member of duty, including one sleep in at night. On occasion, there may be two staff on duty, if there are particular events or activities. There was a discussion with one staff member, who described how proactive her approach was to training within the organisation. This is to be commended. It was clear that much had been learnt and retained from the training sessions attended, which included mental health awareness, which provided insight and understanding of conditions affecting service users with a learning disability; infection control; use of an invasive procedure; as well as other statutory training, such as first aid, drug administration, adult protection and basic food hygiene. This member of staff has a National Vocational Qualification (NVQ) at Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 21 level 2. She would like to develop further knowledge in the area of autism and other conditions that affect people with a learning disability. All staff have completed mandatory training, which is up to date, apart from some staff who attended adult protection training in 2002 and may benefit from refresher training in this. The organisation now aims that all staff will attend NVQ level 2 training. One member of staff is registered to start NVQ level 2. Information was gathered about staff recruitment at a site visit to the OLPA head office in May 2006. As a result of this meeting and a change in guidance, staff recruitment records will be kept in the head office, with a checklist of information being kept in the home. This is being organised by the organisation’s personnel officer, following guidance provided by the CSCI. All the records relating to this home were in order. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from a well run home, where their safety and well being is promoted and protected. Service users are contributing to a review of quality in the home and would benefit from a clearer structure about the process. EVIDENCE: The manager has been in post for several years and is also registered to run another OLPA service, 18 Boundary Road. She is qualified with NVQ level 4 and the Registered Manager’s Award. This is well managed service and the rota clearly shows where the manager may be at any point in the week. The manager continues to work weekends in order to continue supporting the service users. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 23 The organisation have some quality assurance policies and procedures, which describe the following: the Annual General Meeting, service users questionnaires, tenants meetings, managers and team meetings, Regulation 26 visits, external inspections and the cross referencing of standards. The organisation has started to devise a system for gathering the views of service users, relatives and stakeholders. Managers have been asked to send questionnaires out so that information about these views on the quality of the service can be assessed. The form includes a section for comments and for people to think about one thing the organisation could do better. The quality assurance policy and procedure comments on the range of ways that quality had been assessed and this included Regulation 26 visits, which are unannounced visits by a representative of the registered provider and other methods. The policy and procedure needs to be amended to reflect this process. This should include the aims of the questionnaire and how the organisation plans to implement any changes that may be suggested. Fire safety records were checked and these were all in order. The home experienced a small fire a few months ago when the tumble dryer caught fire. Due to the vigilant staff member on duty, who responded appropriately, no person was injured and no major damage was caused. As a result risks have been assessed and recorded. The fire officer reported that he was pleased with the procedures and policies in place. The incident had been properly reported to the CSCI. There are environmental risk assessments in place for the use of a stair gate at night. Some of the risk assessments on self closing doors need to be reviewed as they do not include the fact that there are 4 bedrooms in the home now. Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 N/A 3 X 4 X 5 2 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 4 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 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 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 Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 25 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 YA1 Regulation 5 (1) (c) Requirement The responsible individual must ensure that all service users have a contract in place from the placing authority. (One new service user has a contract in place.) There are unresolved issues with the organisation and the placing authority, which have been an issue for over 2 years now. This was to be actioned by 31st May 2005. Information must be received about the current status of contracts from the Responsible Individual. There must be a quality assurance system in operation and a report must be sent to the CSCI on completion of the survey. COMMENT: The organisation has devised a questionnaire, which is being sent out to stakeholders, relatives and service users. Carried forward from the last inspection, due to be met by 30/04/06 Timescale for action 31/10/06 2. YA39 24 (1) (2) (3) 31/10/06 Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 26 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 YA20 Good Practice Recommendations An outside professional should be part of the training in drug administration that takes place within the organisation. (Carried forward from last two inspections) Staff who had received adult protection training more than two years ago should attend training to update their skills and knowledge. Risk assessments on self closing doors need to be reviewed as they do not include the fact that there are 4 bedrooms in the home now. 2. YA23 3. YA42 Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Mossmead (15) DS0000028274.V292261.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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