Inspection on 17/07/06 for Old Barn Close (4)

This inspection was carried out on 17th July 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Old Barn Close (4) 12/01/09

Old Barn Close (4) 18/01/08

Old Barn Close (4) 22/02/07

Old Barn Close (4) 15/02/06

Old Barn Close (4) 27/09/05

Old Barn Close (4) 15/03/05

Old Barn Close (4) 13/07/04

Old Barn Close (4) 23/02/04

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Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Old Barn Close (4) Gawcott Bucks MK18 4JH Lead Inspector Chris Schwarz Unannounced Inspection 17th July 2006 09:25 Old Barn Close (4) DS0000023095.V298969.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 Old Barn Close (4) DS0000023095.V298969.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. Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Barn Close (4) Address Gawcott Bucks MK18 4JH 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) 01280 821006 01280 821006 4oldbarn@nildram.co.uk Hightown Praetorian & Churches Housing Association Ms Dawn Mayhew Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Ms Mayhew is to have completed her NVQ Level 4 / Registered Managers Award by the 1st January 2007. 15th February 2006 Date of last inspection Brief Description of the Service: 4, Old Barn Close is situated in a quiet residential area of the village of Gawcott. This village is a short distance from the town of Buckingham, which has a variety of shops and other local amenities. Gawcott is served by infrequent local bus services, with more extensive transport accessible in Buckingham. The home is part of the Hightown Praetorian Housing Association. 4, Old Barn Close is a modern bungalow, which is home to 4 male service users with behavioural problems, learning and communication difficulties. The home has an enclosed garden, which provides service users with a safe external area in which they can walk unhindered and in safety. The garden contains swings for service users, and is planted with flowers and shrubs. Entry to, and exit from, the home, has to be facilitated by staff, and an alarm alerts staff if the door is opened at other times. All service users are accommodated in single bedrooms, which possess washbasins. A separate shower and bath are present in the home, as well as a kitchen, laundry, staff sleep over room, dining and lounge areas. All service users are registered with a general practitioner, and access to other healthcare professionals, such as community nurses and dieticians, is through direct contact by staff, or through GP referral. Fees range from £2031.33 to £2140.30 per week. Information supplied by the manager at the time of inspection. Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over the course of one day and covered the key standards for care homes for younger adults (18-65). The process of inspection included discussion with the manager and other staff, a tour of the premises, joining service users for lunch and examination of some of the required records. Prior to the inspection, the home was sent a questionnaire for completion and comment cards for distribution to service users, relatives and visiting health professionals. No replies were received. Staff and service users are thanked for their co-operation and hospitality during this day long unannounced visit. What the service does well: Service user plans are in place for each person living at the home, outlining their care needs in order that they receive the assistance they require. Service users are enabled to make decisions, with assistance from staff, to exercise choice in their everyday lives. Risk assessments are in place to support service users to be as independent as possible. Service users are enabled to take part in activities and pastimes which provide them with stimulation and variety and involvement in the community. Service users are supported to remain in contact with family and friends, to maintain important social contacts. The daily routines within the home are flexible, promoting independence and respecting responsibilities and rights. Mealtimes are well managed, with a range of meals provided for service users, to meet their nutritional needs. Service users receive the personal support they need, ensuring that care needs are met. Staff generally enable physical and emotional needs to be met, helping service users to keep well. Management of medication is well handled, ensuring that service users receive the medicines they require. Effective complaints procedures are in place, to listen to the views of service users’ representatives. Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 6 Adult protection is being effectively handled, to ensure that the risk of harm to service users is minimised. Staff have a good understanding of their roles and repsonsibilities and are competent to provide care to service users. A manager is in place at the home, to ensure consistency of care. Effective monitoring is undertaken by the provider, to ensure that service users receive the care they require. There is due regard for health and safety, to minimise the risk of injury to service users, visitors and staff. A comfortable, clean and homely environment has been created for service users, providing them with a safe and attractive place to live. Needs arising from equality and diversity are well met. What has improved since the last inspection? What they could do better: Flexibility of external activities and use of the home’s transport could be impaired by regular use of the home’s vehicle at a set time for one person. Some attention is needed to making sure that dental care is arranged and that weights are regulalry recorded. Robust recruitment practices are not in place, placing service users at potential risk of harm. A couple of matters need attending to to improve the environmental facilities. Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 7 A medication fridge needs to be used to safely store medicines that require chilling. The office/sleeping in environment needs attention, to provide more spacious facilities. 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. Old Barn Close (4) DS0000023095.V298969.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 Old Barn Close (4) DS0000023095.V298969.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: There have not been any new admissions to the home therefore the key standard in this section was not covered. Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. 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 from evidence gathered during the inspection, which included a visit to the service. Service user plans are in place for each person living at the home, outlining their care needs in order that they receive the assistance they require. Service users are enabled to make decisions, with assistance form staff, to exercise choice in their everyday lives. Risk assessments are in place to support service users to be as independent as possible. Some information needs to be updated to ensure that documentation is accurate. Archived records need more appropriate storage. EVIDENCE: A sample of care plans was examined and found to be in good order overall with detailed information about the care needs of each person, including communication needs and information about challenging behaviour. Most of the information was up-to-date, with evidence of reviewing care needs and Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 11 amending documentation to reflect changes in circumstances. Some information did not show evidence of reviewing from 2004 and needs to show that evaluation is taking place at least on an annual basis. Files contained copies of review meetings involving Social Services and other relevant parties. Archiving of care plan and accompanying files has taken place in the time that the manager has been at the home, however, documents are being stored in service users’ bedrooms. This raises potential issues with the security of such arrangements and access to confidential reports from other agencies by unauthorised persons. The manager will need to ensure that such records are stored more appropriately in secure facilities. The home has a missing persons procedure and it was confirmed that no one had been missing. Risk assessments are in place for a range of every day activities, such as using the kitchen, accessing the local swimming pool, being out in the community and managing challenging behaviour. From observation of practice, it was possible to see that service users are enabled to make decisions, such as whether they want to go out swimming, what they would like to drink, where they would like to sit and given the opportunity to be alone or in company. Staff manage service users’ money effectively and check their individual locked tins at handover to verify the recorded balances. Receipts are kept to explain expenditure, as well as transaction records. Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. 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 from evidence gathered during the inspection, which included a visit to the service. Service users are enabled to take part in activities and pastimes which provide them with stimulation and variety and involvement in the community. Flexibility could be impaired by regular use of the home’s vehicle at a set time for one person. Service users are supported to remain in contact with family and friends, to maintain important social contacts. The daily routines within the home are flexible, promoting independence and respecting responsibilities and rights. Mealtimes are well managed, with a range of meals provided for service users, to meet their nutritional needs. Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 13 EVIDENCE: Daily notes and care plan documents provided evidence of service users being involved with a range of activities and pastimes, such as lunch out, multisensory sessions, swimming, walks, cookery sessions, picnics, gardening, barbeques and making use of local pubs and shops. The home has its own vehicle to transport service users. At the last inspection, it was highlighted that the arrangements to take one service user to stay at his parental home for part of the week impinge on both staffing resources and the availability of the vehicle and timing of activities for other people. The arrangement is still in place but there was written evidence from review notes of the matter being pursued by Social Services. The impact upon the rest of home is still of concern, as observed when the service user did not want to leave and the knock on effect this would have for staff covering the home until 6.00 pm, and the difficulty the manager was having finding staff to cover 3.00 pm to 6.00 pm shifts to facilitate the arrangement. Until the requirement from last year is met, the standard is scored as unmet. The lunchtime meal was well managed by staff, with ample support for service users who needed it. Menus reflected a variety of meals available to service users and the scrambled egg on toast with spring onions and herbs added to it was well received, as was the fresh fruit salad that staff had prepared. Service users have been given the opportunity to take part in basic cookery sessions, via involvement at the home from Aylesbury College, and feedback from staff was positive and indicated that service users are benefiting from the input. Daily reports and photographs provided evidence that service users have contact with their family and friends. A barbeque held recently had been well attended and looked enjoyable. The home’s routines were seen to be flexible, with service users’ bedroom space respected when they were out and the freedom for them to be alone or in company. Service users were free to have access around the premises and involvement in household tasks, such as clearing away after lunch, was encouraged. There was no need for rules to be in place on the use of alcohol, smoking and drugs. Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. Service users receive the personal support they need, ensuring that care needs are met. Staff generally enable physical and emotional needs to be met, helping service users to keep well. Some attention is needed to making sure that dental care is arranged. Management of medication is well handled, ensuring that service users receive the medicines they require. Use of a medication fridge is needed to appropriately store one medicine. EVIDENCE: Care plans provide information on the support each person needs and there are records of incontinence, episodes of challenging behaviour and weights, although in some cases weights had not been recorded since January this year. It is recommended that more frequent weighing takes place. Records are maintained of medical appointments attended by service users and the outcomes of these. These records showed that a range of health care Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 15 professionals is involved with service users’ care but there was not consistent attendance for dental appointments. A requirement is made to ensure that service users receive regular dental checks. Medication cabinets have been added to each bedroom and these are secure wall mounted cabinets. Staff check each cabinet and contents as part of handover and document this. Each was locked when not in use and records of administration were in good order. Use of “as required” medications was documented and witnessed by a second person. There was little use of these medicines in relation to the frequency of challenging episodes. The manager contacted the consultant in learning disability’s office to report concerns about one person which were escalating on the day of inspection, resulting in a domiciliary visit being arranged for the following day. A requirement was made at the last inspection to obtain a medication fridge, as one person’s medicine is being stored in a locked box in the fridge. A fridge has been obtained but is not being used. The requirement is repeated. Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. 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 from evidence gathered during the inspection, which included a visit to the service. Effective complaints procedures are in place, to listen to the views of service users’ representatives. Adult protection is being effectively handled, to ensure that the risk of harm to service users is minimised. EVIDENCE: Procedures for making complaints, whistle blowing and protecting vulnerable adults from abuse were seen and found to be adequate. There had not been any complaints about the service since the last inspection, according to the log book at the home, but two compliments from relatives were noted. The Commission has not received any complaints direct and no adult protection concerns have been notified. The manager has completed a train the trainer adult protection course, run by Social Services. Courses for staff who have not already attended adult protection training were booked and there was email confirmation from the provider to verify places had been reserved. The Commission is not aware of any complaints or adult protection issues for this service. Challenging behaviour is documented and seemed to be handled more effectively by staff. Comment was made to the manager about a protocol in place for one of the service users who needs to be directed to private areas of Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 17 the home at times. It was observed that staff were not consistently following guidance for part of the inspection but improvement was noted during the afternoon. Staff meeting minutes showed that a member of staff from human resources had joined a meeting to discuss completion of new accident and incident forms, meeting a requirement made at the last inspection. Staff were also notifying the Commission of incidents involving service users harming themselves or others. Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 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): Quality in this outcome area is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. A comfortable, clean and homely environment has been created for service users, providing them with a safe and attractive place to live. A couple of matters need attending to to improve facilities. EVIDENCE: The home is a large detached bungalow at the end of a quite cul-de-sac in the village of Gawcott. All bedrooms are single and have been decorated and arranged to different tastes and personalised. All areas of the home were light and airy and well ventilated and communal rooms were comfortable and of adequate size for the number of service users. Curtains have been replaced in the dining room, hall and office and redecoration has taken place to some of the communal areas. One of the lounge sofas no longer provides adequate support and should be disposed of. The kitchen was well stocked with food and the laundry was clean and in good order. In one of the two bathrooms a pool of water was standing by the drain in the floor – it is recommended that this be checked to ascertain whether there is a problem with drainage, and if so this must be rectified. Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 19 There was an absence of soap in bathrooms and therefore nothing for service users to wash hands with. Soap must be provided to ensure proper hand hygiene measures are in place and a requirement is made to attend to this. The garden is well maintained and since the last inspection a greenhouse has been added with tomato plants and herbs, runner beans, chillies and peppers were growing in the flower beds. Four different seating areas are available in the garden and a gazebo was providing further shade. Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 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 and 35 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. Robust recruitment practices are not in place, placing service users at potential risk of harm. Training is being improved, to ensure that service users are cared for by staff who have sufficient skills to meet their needs. Staff have a good understanding of their roles and repsonsibilities and are competent to provide care to service users. EVIDENCE: The recruitment files of three newer staff were looked at. The full range of required checks was not in place for any of the staff, with documents such as references, proof of identification and a photograph of the person missing. A requirement is made to ensure that the full range of checks are in place before staff work at the home, and for these to be available for inspection purposes. Monitoring visits by the provider should also include a check of these files. Staff seemed to have a good understanding of their roles and responsibilities. Handover from one shift to the next is well managed with verbal and written Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 21 instruction taking place and four staff meetings have taken place so far this year. There is a comprehensive induction programme for staff with evidence of completion for two of the three new starters. The third person’s induction records were not available at the home. Improvements to mandatory training were being made with evidence of further courses booked for staff to attend. Until these courses have been attended, the requirement made at the last inspection will not be met and is repeated, for assessment during the next visit. Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 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 and 42 Quality in this outcome area is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. A manager is in place at the home, to ensure consistency of care. Effective monitoring is undertaken by the provider, to ensure that service users receive the care they require. There is due regard for health and safety, to minimise the risk of injury to service users, visitors and staff. EVIDENCE: The manager is registered with the Commission and is undertaking the Registered Manager’s Award. Until this has been achieved, the standard cannot be scored as met and this should not be viewed as a reflection of managers’ abilities. Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 23 Regular monitoring visits are undertaken by the provider with reports sent to the Commission of the findings. An unannounced monitoring visit was taking place at the time of this inspection. The manager confirmed that the provider had undertaken a quality assurance exercise at the home although the report of this was not available yet. A range of health and safety checks is undertaken at the home, including weekly fire testing, fire drills, fridge and freezer temperature checks, hot water temperature testing, cooked food temperatures and visual hazards around the premises. A fire based risk assessment was in place, which is due for review now. Some generic risk assessments were in place and were up-to-date. There was appropriate disposal of clinical waste and records showed that staff record accidents and incidents. A gas safety certificate was in place dated August 2005. Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 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 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 X 12 3 13 2 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 x 3 x x 3 x Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 2 3 4 Standard YA6 YA6 YA19 YA35 Regulation 15(2) 10(1) 13(1) 18(1) Requirement All care plan documentation is to show evidence of at least annual review. Archived information is to be stored in secure facilities, rather than service users’ bedrooms. Regular dental checks are to be arranged for service users. All staff will receive training and updates in mandatory training to include - fire safety, moving and handling, food hygiene. Previous timescales, the most recent 01/03/06, not met. The regular transporting home arrangement for one service user is to be reviewed, to result in removal of restrictions in accessing the community for others. Previous timescale of 01/04/06 not met. A medication fridge is to be obtained and used. Previous timescale of 01/04/06 not met. Soap is the be available in bathrooms and toilets at all times. DS0000023095.V298969.R01.S.doc Timescale for action 01/10/06 01/09/06 01/12/06 01/12/06 5 YA13 10(1) 01/12/06 6 YA20 13(2) 01/08/06 7 YA24 13(4)c 15/08/06 Old Barn Close (4) Version 5.2 Page 26 8 9 YA24 YA34 16(2)c 19(1) 10 YA35 13(6) The broken sofa is to be disposed of. The full range of required schedule 2 checks is to be in place before start work at the home and available in their files for inspection. Protection of Vulnerable Adults training is be updated and thereafter attended annually. Previous timescale of 01/06/06 not met. 15/08/06 15/08/06 01/12/06 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 YA24 Good Practice Recommendations It is strongly recommended that the organisation review the staff office / sleep-in room, with a view to an improvement of these facilities and the provision of secure storage for residents records that does not impinge on residents communal space. A health and safety assessment is to be undertaken of the office space and forwarded to the Commission. Service users are to be weighed on a regular basis. Drainage in the bathroom floor should be investigated. Monitoring visits by the provider should include checking of recruitment files for all required documentation. 2 3 4 YA19 YA24 YA39 Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury 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 Old Barn Close (4) DS0000023095.V298969.R01.S.doc Version 5.2 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. 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