Inspection on 21/12/07 for Old Ford End

This inspection was carried out on 21st December 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Old Ford End 03/03/09

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Old Ford End 74 Old Ford End Road Bedford MK40 4LY Lead Inspector Mr Pursotamraj Hirekar Key Unannounced Inspection 21st December 2007 12:40 Old Ford End DS0000070533.V356850.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 Ford End DS0000070533.V356850.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 Ford End DS0000070533.V356850.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Ford End Address 74 Old Ford End Road Bedford MK40 4LY 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) 01543 442500 londonroad@tiscali.co.uk Milbury Care Services Ltd Vacant Care Home 6 Category(ies) of Learning disability (6), Physical disability (5) registration, with number of places Old Ford End DS0000070533.V356850.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC. To service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD. Physical disability - Code PD. The maximum number of service users who can be accommodated is: 6 NA 2. Date of last inspection Brief Description of the Service: The home is a new build and had been finished to a high standard with regard to fixtures, furnishings, and décor. The home is located in a residential part of Bedford in Bedfordshire, in close proximity to local facilities (Bedford town centre) and transport links. There were six en-suite bedrooms – five of these were on the ground floor. Five of these were fitted with a toilet, hand basin, and shower. An additional bathroom and separate toilet were also in place on the ground floor. On the 1st floor the 6th bedroom had been designed as a bed-sit and comprised of its own bathroom with overhead shower, sleeping, kitchen, and dining area, this could accommodate someone looking to develop his or her independent living skills. All bedrooms were of a good size and the ground floor bedrooms and bathrooms had been fitted with overhead tracking. There was no PD access to the 1st floor and 6th bedroom. All of the bedrooms had been individually decorated and included a bed, a chair a table, a touch operated lamp and matching curtains and bed linen. In addition to the bedrooms and bathrooms the premises included a lounge, activity/sensory room, an open kitchen/dining room, laundry, office, a number of store cupboards, a fully enclosed garden and parking for several cars to the front of the property. A TV and a music system were available for service users within the communal areas. The current fee was in the range of £1500/- to £1800/-. There is no registered manager. Old Ford End DS0000070533.V356850.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the first unannounced inspection carried out on 21/12/07 by Pursotamraj Hirekar over 5 hours. The manager and the senior staff coordinated the inspection. The method of inspection included study of care plans, risk assessments, personnel records, staff deployment duty rota, relevant care delivery documents, discussions with manager and staff, conversation with service users’ and partial tour of the building. The annual quality assurance assessment self-assessment information provided by the home is included for analysis and preparation of this report as well. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure to complete assessment of all elements of health and personal care for all service users and are reflected in their individual care plans. The home must ensure that all service users individual specific risk assessments and risk management strategies are carried out and changes are reflected in the individual care plan as well. The home must ensure that adequate staff ratio and staff deployment is maintained all the time in response to the needs of the service users including appropriate contingency plans to mitigate any staff member absences. The home must ensure that the staff supervision meetings are held. The home must ensure that each individual service users’ risk assessments are upto date, to ensure service users are protected from the risk of harm. The home must carry out nutritional assessment for each individual service user and are regularly reviewed. The home must develop health action plan for each individual service user. Old Ford End DS0000070533.V356850.R01.S.doc Version 5.2 Page 6 The home must ensure that the guidance under the medication policy and practice manual of the home is strictly adhered to. The home must ensure that at all times suitably qualified, competent and experienced persons are working in such numbers as are appropriate for the health and welfare of service users. The home must make appropriate arrangements for the manger to give essential time for completing management functions without causing any delays that would impact upon the service users. The home must ensure that the manager had relevant qualification level 4 NVQ, in management and care. The home must have effective quality assurance and quality monitoring systems, based on seeking the views of service users and relevant stakeholders to measure success and make improvements where required. The home must ensure that faults identified during water temperature checks are rectified without undue delay. Each service user must be provided with an individual written contract or statement of terms & conditions, which must include the amount and method of payment of fees. The home should evidence that the service user or a representative have participated in the assessment of needs of the service user. The home should ensure that all the service users’ are engaged in appropriate local, social, and community activities. The home should ensure service user or their representative consent to medication is obtained and recorded in individual care plan. Old Ford End DS0000070533.V356850.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Old Ford End DS0000070533.V356850.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 Ford End DS0000070533.V356850.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): 2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was evidence that the home had assessed the needs of the service users. However, the service users contracts were not in place, to ensure service users and or their representatives received the details of services. EVIDENCE: There was evidence that the home had assessed the needs of the service users. The assessment detailed reason for referral, medical overview, personal hygiene, elimination, eating and drinking, communication, mobility, daily routine, work & leisure, sexuality, beliefs, individuality and concluded that the service user would be suitable for the home, benefit from living with people with her own age, ability and in an environment that would allow her to access more community presence and also to enable her to complete daily living skills to enhance the potential she already has. The home was able to demonstrate that it could meet the assessed needs of individuals admitted to the home. Staff individually and collectively demonstrated that they had the skills and experience to deliver the service and care which the home said it could provide. However, the individual service users whose lives were tracked as part of this inspection process, their needs assessments had no information about person Old Ford End DS0000070533.V356850.R01.S.doc Version 5.2 Page 10 who carried out the assessment and the home did not evidence that the service user or a representative have participated in the assessment of needs of the service user. The service users contracts were not in place; the manager informed during the inspection that the contracts should be concluded by second week of January 2008. Old Ford End DS0000070533.V356850.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 adequate. This judgement has been made using available evidence including a visit to this service. Service user plans and risk assessments were insufficient. However, further development was needed to ensure they are drawn up involving others as appropriate, in a suitable format for the service users to understand. Therefore minimising risk to service user’s and supporting them to understand and participate in decisions about their needs and personal goals. EVIDENCE: A sample of 2 people using services, their care plans and supporting documentation were examined and found that the plans did not contain sufficient information to help meet generally their changing needs and personal goals that were identified and reflected in their individual plan. The care plan had detailed information under assessed need, strengths, short-term goal, long-term goal, and how to deliver support for daily routine, personal care, medication, physical health, diet, mobility, behaviour, activities and holidays, social skills, living skills, communication support plan did not have makaton symbols being in use, but the person using the service was assessed as can say few words also use makaton signing and need encouragement to do so Old Ford End DS0000070533.V356850.R01.S.doc Version 5.2 Page 12 which was not in practice at the home. Weekly plan for am, pm and evening was incomplete, decision-making plan incomplete, relationships incomplete, cultural and spiritual plan incomplete, ageing, death and illness no plan in place and health action plan was yet to be initiated. Apart from moving and handling, risk assessments were not in place for individual service users within the home, which could support individual service user plans. There was no evidence that the service user’s family, friends or advocate had been involved in completing the plans and none were available in a suitable format that the service user could understand, and service users those who were case tracked neither they or their representative had signed service user plan. There was no evidence provided that the care plans had been reviewed at regular intervals and changes reflected in the care plan. For example the advice received from the occupational therapist, physiotherapist and health professionals given was not reflected in the support plan. On the 3/10/07 doctors advice and change of medication was not reflected in the support plan. 30/10/07 on examination by the visiting nurse recorded that the antibiotics were finished on the 2/10/07 and advised oral medication and this was not reflected in the care plan and the daily log had no mention about the same. Which means there was no consistency of information across the various records. The manager informed on this inspection that, by the end of January 2008 each individual service user care the plans would be updated with makaton signs and reviewed regularly every month and changes reflected, including completion of health action plan. There was evidence from speaking with service users and records examined that service users were assisted as necessary to make decisions about their daily lives. Information about the homes’ policies, procedures, activities & services of the home were not available in suitable formats, to enable people using services to understand and participate fully in all aspects of life within the home. Old Ford End DS0000070533.V356850.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 adequate. This judgement has been made using available evidence including a visit to this service. The home had made arrangements for the service users to pursue meaningful leisure activities, relationships, & community links. However, the home needs to further develop weekly activities for each individual service user during the week, in line with the needs and risk assessment outcomes and evidence nutritional assessments of people using services. EVIDENCE: It was evident that service users were given the opportunity for personal development. The home supported service users to attend hydrotherapy, aromatherapy, snoozlum, corner club, and church during the week and was supported by physiotherapist and occupational therapist as well. However, the home needs to further develop weekly activities for each individual service user during the week, in line with the needs and risk assessment outcomes. On the day of this inspection, 2 service users were observed returning from hydrotherapy session escorted by the manger, the service user appeared relaxed. Old Ford End DS0000070533.V356850.R01.S.doc Version 5.2 Page 14 There was evidence that the home supported service users to maintain family links in accordance with their wishes. Several service users spoken to have said they were supported by the home to visit their family. A mealtime was observed, staffs were observed supporting those service users who needed help while eating, which demonstrated a flexible approach to their support. Service users were offered a choice of menus and were actively supported to help plan meals. However, there was no evidence that service user’s nutritional needs had been assessed. Staffs were observed knocking on service user’s bedroom doors before entering and waiting to be invited into their bedrooms. Old Ford End DS0000070533.V356850.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 adequate. This judgement has been made using available evidence including a visit to this service. The home had a suitable medication policy and staff had received satisfactory training in medication administration. However, The home needed to complete health action plan for all the people using services, to safeguard their wellbeing and prevent placing them at potential risk. EVIDENCE: Service users spoken to said they enjoyed living at the home and that they felt supported by the staff. Records viewed suggested service users received personal support in the way they preferred and most were encouraged to maximise their independence. This was supported by observations and discussions held with service users. There was evidence that the home accessed outside healthcare professionals and services as required; in order to meet the healthcare needs of the service users. Samples of medication records, storage, and procedures were checked, of those service users whose lives were being tracked as part of this inspection. Staff had received satisfactory training in medication administration. No Old Ford End DS0000070533.V356850.R01.S.doc Version 5.2 Page 16 service users were responsible for administering their own medication within the home. The homes procedures for the administration of medication were appropriate. However, the home had received a complaint on 22/10/07 from parent of a service user for not taking prior consent for a flu jab without knowing if it had already been done prior to service user moving into the home. The medication policy and practice manual of the home clearly states that under section 4.5 as far as practicable, the service user’s consent to receive medication should be obtained and recorded in their individual service user’s personal plan at the time that the medicine is prescribed. However, this was not followed by the home. The home had no controlled drugs on this day of inspection. The home needed to complete health action plan for all the people using services. Old Ford End DS0000070533.V356850.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 adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for protecting service users were satisfactory. However, further improvement was needed to ensure appropriate monitoring and practice of administration of medication procedures, as set out in the home’s manual to protect service users from possible neglect. EVIDENCE: The home had a satisfactory complaints policy and procedure in place, which enabled them to deal with complaints received. The complaints procedure needed to be produced in an illustrated, picture format for service users with limited communication skills. A record was kept of all complaints. The home had received a complaint on 22/10/07 from parent of a service user for not taking prior consent for a flu jab without knowing if it had already been done prior to service user moving into the home. The medication policy and practice manual of the home clearly states that under section 4.5 as far as practicable, the service user’s consent to receive medication should be obtained and recorded in their individual service user’s personal plan at the time that the medicine is prescribed. However, this was not followed by the home. The current manager had appropriately responded to the complainant by saying that this would not happen future. But, there was no evidence provided on this inspection that the home had obtained consent from all the parents/representatives of people using services for medication. Old Ford End DS0000070533.V356850.R01.S.doc Version 5.2 Page 18 The homes policies and practices regarding service users money and financial affairs were generally satisfactory and protected service users from abuse. A sample service users’ cash and money management records reconciliation was carried out and was found satisfactory. Old Ford End DS0000070533.V356850.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 good. This judgement has been made using available evidence including a visit to this service. The home was maintained clean and tidy and there were no offensive odours. However, action needed to be taken with regard to hot water of cupboard sink, to prevent any harm to the service users’ and staffs as well. EVIDENCE: A couple of service users bedroom were observed to reflect their needs and lifestyle. All rooms were single occupancy with en suite provision. Service users spoken to were clearly happy with their individual bedrooms. The records provided on this inspection indicated that, the home had regularly carried out health safety checks and weekly fire audit. However, the hot water temperature for cleaning cupboard sink recorded 61.5 recorded very hot water can burn, reported to manager in October, November and December 2007 no action had been to taken to correct the situation, the manager said she reported to the maintenance people but no action was taken as yet. Old Ford End DS0000070533.V356850.R01.S.doc Version 5.2 Page 20 Toilets and bathrooms appeared adequate and provided sufficient privacy. The home appeared clean and free from offensive odours, service users, care staff and night staff were responsible for ensuring this was maintained. The EHO report of 11/09/07 identified no issue and reported as good. Old Ford End DS0000070533.V356850.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, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users were supported by the home’s recruitment policy and procedures. The staff and the service users’ had good working relationship. However, the home must revisit staffing levels and staff deployment, to meet the assessed needs of all the people using service and enable the manager to complete management functions. EVIDENCE: Staff spoken to have identified varied training which they had undertaken at the home and this was supported by evidence in their training records. The home was able to access a structured corporate training plan. Which offered them the opportunity to nominate staff to attend varied statutory and specialist training, relevant to their roles and service user’s needs. However, staff training records and training plan need to be updated. There was evidence that some staff had received specialist training to support them to meet the needs of the service users. Observations made and staff spoken to had a good understanding of service user’s communicating needs, preferences, and frustrations. Morale within the home was high amongst staffs, which was reflected by staff spoken to, one staff member said, “we work as a team, and we feel supported by our manager”. However, the home has had 11 permanent care staff, out of which only 3 staff has had NVQ level 2 Old Ford End DS0000070533.V356850.R01.S.doc Version 5.2 Page 22 qualification or above, the percentage of staffs with NVQ qualification was lower than the required national minimum standards. One of the service user commented that ‘the home should have care staff who know about care rather then people who think they know’. The home needed to look into this and improve upon. The home had 3 shifts staff deployment system, early, late and night shift. The early shift had 3 staff members; the late shift had 2 staff members and 1 sleeping and 1 walking for the night shift. The staff ratio appeared to be inappropriate in relation to the service users’ needs; the manager and all the staff spoken to on this inspection had voiced this concern as well. For example, on this day of the inspection the manager had taken 2 service users’ for hydrotherapy session and the manager was expected to cover duty at least 3 days in a week, which made difficult for the manager to complete management functions, the manager informed on this inspection. Staff files that were examined, demonstrated that the home had obtained satisfactory checks and clearances on staff before their commencement, therefore the home was able to demonstrate that service users were protected by the home’s recruitment policy and practices. Recruitment practices appear to be robust however, a summary sheet was made available on this inspection and the actual records were held at the head office, the manager said. Staff spoken to had not received regular supervision. The manager informed that, she was in the process of scheduling monthly staff supervision. Old Ford End DS0000070533.V356850.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 adequate. This judgement has been made using available evidence including a visit to this service. The home need to provide appropriate working hours for the manager to perform and achieve management objectives and ensure effective quality assurance system and process are in practice in the best interest of the service users’. EVIDENCE: Currently the home does not have a registered manager. The current manager was in post since November 2007 and was in the process of making an application for registered manager with the commission. The manager had been working in the care sector for 18 years, predominantly, with the elderly and with learning disability user group since May 2007. The manager coordinated the inspection. The manager, staffs, and people using services have good working relations. This was apparent from the discussions held and observations made of the staff members and people using services. However, the manager was unable to perform managerial functions such as completion of service user risk assessments, updating care plans, carrying out care plan Old Ford End DS0000070533.V356850.R01.S.doc Version 5.2 Page 24 reviews, staff supervisions, and maintaining records due to inappropriate staffing levels and staff deployment and duty cover by the manager. The home need to make appropriate arrangements for the internal monitoring and maintaining quality assurance system within the home that need to be successfully achieved. The home needs to regularise regulation 26 visits and reports presented. Staffs’ supervision needed to be regularly carried out to benefit the service users and the staffs as well. There was evidence that the home maintained general risk assessments, including health & safety and fire. However, the hot water temperature for cleaning cupboard sink recorded 61.5 recorded very hot water can burn, reported to manager in October, November and December 2007 no action had been to taken correct the situation, the manager said she reported to the maintenance people but no action taken as yet. Old Ford End DS0000070533.V356850.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 X 2 2 3 X 4 X 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 2 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 2 X Old Ford End DS0000070533.V356850.R01.S.doc Version 5.2 Page 26 NA 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 YA6 Regulation 15 (1) Requirement The home must ensure to complete assessment of all elements of health and personal care for all service users and are reflected in their individual care plans. The home must ensure that all service users individual specific risk assessments and risk management strategies are carried out and changes are reflected in the individual care plan as well. Timescale for action 25/02/08 2. YA9 15(2) 25/02/08 3. YA13 16 (2) (m) 4. YA24 13 (4) The home must support each 01/02/08 individual service user to become part of, and participate in, the local community in accordance with assessed needs and the individual plan. The home must ensure to rectify 10/01/08 faults identified through water temperature check to avoid any harm to service users and staff. The home must ensure that adequate staff ratio and staff deployment is maintained all the time in response to the needs of the service users including DS0000070533.V356850.R01.S.doc 5. YA33 18 25/02/08 Old Ford End Version 5.2 Page 27 6. 7. YA36 18(2) 23 (2) (p) YA42 8. YA17 16 (2) (i) 9. 10. YA19 12 13 (6) YA23 11. YA32 18 (1) (a) 12. YA37 9 13. YA37 9 14. YA39 24 appropriate contingency plans to mitigate any staff member absences. The home must ensure that the staff supervision meetings are held. The home must ensure that each individual service users’ risk assessments are upto date, to ensure service users are protected from the risk of harm. The home must carry out nutritional assessment for each individual service user and are regularly reviewed. The home must develop health action plan for each individual service user. The home must ensure that the guidance under the medication policy and practice manual of the home is strictly adhered to. The home must ensure that at all times suitably qualified, competent and experienced persons are working in such numbers as are appropriate for the health and welfare of service users The home must make appropriate arrangements for the manger to give essential time for completing management functions without causing any delays that would impact upon the service users The home must ensure that the manager had relevant qualification level 4 NVQ, in management and care. The home must have effective quality assurance and quality monitoring systems, based on seeking the views of service users and relevant stakeholders to measure success and make improvements where required. DS0000070533.V356850.R01.S.doc 01/02/08 25/02/08 25/02/08 25/02/08 01/02/08 25/02/08 25/02/08 30/03/08 01/02/08 Old Ford End Version 5.2 Page 28 15. YA42 23 (2) (P) 16. YA5 5 (1b) & (1c) The home must ensure that faults identified during water temperature checks are rectified without undue delay. Each service user must be provided with an individual written contract or statement of terms & conditions, which must include the amount and method of payment of fees. 30/12/07 01/02/08 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 YA2 Good Practice Recommendations The home should evidence that the service user or a representative have participated in the assessment of needs of the service user. The home should ensure that all the service users’ are engaged in appropriate local, social, and community activities. The home should ensure service user or their representative consent to medication is obtained and recorded in individual care plan. 2. 3. YA12 YA20 Old Ford End DS0000070533.V356850.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Inspection Team Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Old Ford End DS0000070533.V356850.R01.S.doc Version 5.2 Page 30 - 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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