Inspection on 10/05/06 for Old Manse The

This inspection was carried out on 10th May 2006.

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

Other inspections for this house

Old Manse The 13/02/07

Old Manse The 16/01/06

Old Manse The 11/10/05

Old Manse The 18/03/05

Old Manse The 25/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Old Manse The The Old Manse 243 Main Road Biggin Hill Kent TN16 3JY Lead Inspector Ann Wiseman Unannounced Inspection 10th May 2006 08:00 Old Manse The DS0000006970.V292221.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 Old Manse The DS0000006970.V292221.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. Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Old Manse The Address The Old Manse 243 Main Road Biggin Hill Kent TN16 3JY 01959 571695 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) www.care-ltd.co.uk CARE (Cottage and Rural Enterprises Ltd) Mrs. Pethrona Fray Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 8 Adults of either sex with a learning disability within the category mental handicap 16th January 2006 Date of last inspection Brief Description of the Service: The Old Manse is a detached two-storey house situated in the High Street at Biggin Hill. It has been converted to meet its present purpose as a care home. Shops and public transport links are within easy walking distance. The home is registered to provide care for eight service users with learning disabilities. The communal areas are on the ground floor and consist of a lounge, kitchen/diner, utility room and three bedrooms. Each one has a wash hand basin, and is wheelchair accessible. On the ground floor is a bathroom and shower room. On the first floor, via a flight of stairs, are five bedrooms with en suite facilities. All bedrooms have TV sockets and an alarm call system. There is a large back garden, which is accessible via a ramp. There is a garage at the side of the house and off-street parking at the front. Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the Inspector arrived in time to witness the dispensing of the morning medication. All of the Service Users were either getting ready to go to day centre or having breakfast. The Inspection was facilitated by the Assistant Manager as the Registered Manager was on annual leave. Service Users and staff on duty were friendly and welcoming and the Inspector would like to that everyone involved. The Inspector meet all the Service Users and spoke privately with two of them and was able to speak with two staff members and two family members at a later date by telephone. The commission has sent User Surveys to all the Service Users, their families and other professionals involved with home. The Inspector returned to the home at a later date to speak with the Manager The house was clean and tidy and the atmosphere was friendly and congenial, interaction between the staff and Service Users was friendly, and staff responded in a supportive and respectful manner. Health and safety checks were randomly inspected and those looked at were up to date and in order. Overall the home was found to be comfortable and able to meet the needs of the Service Users , people are given opportunities to take risks as part of an independent lifestyle and the Service Users reported being happy in their home. However the Inspector has reservations concerning staffing levels in the home and practises of staff working alone both in the house and while driving the house car and mini bus. What the service does well: What has improved since the last inspection? The kitchen floor has been replaced and is now serviceable and hygienic and a cupboard in the kitchen that had been water damaged has been replaced. Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 6 Guidelines have been put in place that means staff will not do two sleep in duties in a row and therefore will lessen the risk that Service Users may be at danger because staff are working while being overtired. A system has been put in place that makes it easier to keep track of medication that is sent to family homes with the Service User and returned again. The medication was all in order at the time of this Inspection. What they could do better: 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 Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 7 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 Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 8 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): Key standard 2 was examined on this occasion. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. All prospective Service Users have their needs and aspirations assessed prior to their moving into the house. EVIDENCE: This area has been examined fully on the previous Inspection in January 2006 and all expected requirements were found to be in place. Two Service Users files were examined in detail on this occasion and evidence was seen that their needs and aspirations were assessed and continue to be reviewed. The home has a vacancy and the Manager has assured the Inspector that the required procedure will be followed as they receive any new Service User into The Old Manse. Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 9 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): All standard in this section were assessed on this occasion. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. Service Users are supported to make decisions about their lives and are consulted the running of the house and it’s daily life. Service Users are allowed to take risks as part of an independent lifestyle. EVIDENCE: On this occasion the Inspector looked at two Service User files in detail and found that the Care Plans in the Service Users files are detailed and cover all aspects of their lives and each Service User has their needs and aspirations reassessed each year at a review meeting. Service Users are given opportunities to make decisions about their lives and day to day activities. During the Inspection staff members were observed giving people the alternative options on when to eat and what they wanted for lunch, one Service User was given the opportunity to go shopping with the staff that day and choice of where they would go. Group discussions are encouraged when a decision that will effect them all is needed, where to go for the annual holiday for example. If a consensus it not Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 10 reached on the holiday, attempts will be made to find a Service User from one of the other houses in the group that would like a similar holiday. The house has user meetings regularly which are recorded and outcomes are actioned. Risk assessments are done in many areas of the Service Users lives and interventions put in place to enable the Service User to take risks as part of an independent likes. Service Users file are stored in the office in a locked filing cabinet and are not left out for others to read. Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 11 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): All areas were examined during this Inspection. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. Service Users have the opportunity to attend adult education and to take part in appropriate leisure activities and engage in the local community. EVIDENCE: Service User files showed evidence that the Service Users attend adult education classes such as communication skills, computer club and words, numbers and discussion. Al Service Users attend a day centre and pick and chose what sessions they want to attend. One Service User works at a Charity Shop. Service Users take part in the local community by shopping, eating out, using public transport and some attend the local Church and Bible class and one Service User has recently been baptised. Family contact is supported and encouraged and some of the Service Users visit their family homes for overnight and weekend stays. Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 12 In discussion with staff is was evident that they understand the need to respect and uphold Service Users rights and that they support them to take responsibility for respecting others rights as well as their own. The fridge and freezer contained ample quantities of food and the menus, that are written in consultation with the Service Users, were varied and interesting. An alternative is offered on request. Meals that were served during the inspection appeared well cooked and appetising. Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 13 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): Key standards 18, 19 and 20 were inspected on this occasion. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. Care Plans detail personal needs, including preferences. All Service Users are registered with their local GP and medication is managed efficiently. EVIDENCE: Care Plans clearly show support needs and notes preferences in the way the Service Users want to receive personal care. One Service User needs extra support and has been allocated extra hours. At a previous inspection it was unclear when and how these hours were allocated. A new member of staff has been recruited specifically to cover the extra allocated hours and a clear schedule has been developed. Evidence was noted in Service Users files that shows they receive appropriate medical treatment, there are reports from doctors and hospital appointments and also reports from other health service professionals such as occupational health and psychology. The Inspector was present while the morning medication was being taken and saw it to be administered and recorded as required. The medication is stored in a cabinet that is kept locked and is secured to the wall. Previously it was unclear what medication was taken with Service Users when they stayed with families. A record system has been implemented. Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 14 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): Both standards were examined during this Inspection. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. Complaint procedures are in place and required Protection of Vulnerable Adult Training is given. EVIDENCE: The Commission has been made aware of one complaint that had been made on behalf of one of the Service Users parents. The house has been investigating this complaint that evolved around a Service User being escorted on a hospital appointment by a bank staff member, the Service Users mother also attended the appointment and was unhappy about her sons appearance and was concerned the he was not given appropriate supervision when leaving the hospital. This complaint is still in progress and is being investigated by the Locality Manager. It has been clearly recorded and progress tracked in the homes complaints log. The Inspector would like to be kept informed of its progress and outcome. Please see Requirement 1 Staff attend POVA training and are checked against the POVA list prior to them taking up post, the recruitment process helps to protect the Service Users against abuse. Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 15 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): Key standards 24 and 30 were examined on this occasion. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. The Old Manse is homely, comfortable and is kept clean and hygienic. EVIDENCE: The house is accessible, safe and well maintained and provides the Service Users with an environment that is homely in aspect. There is an abundance of personal items, photos and ornaments around the home, the furniture is serviceable and comfortable looking, the decoration is in a modern, domestic style that the Service Users have helped to chose. The large rear garden is easily accessed from the kitchen and lounge, with wide doors and a ramp with hand rails. The building is maintained in a way that promotes a safe environment. The home is kept clean and hygienic by staff with some input from the Service Users who are supported to keep their rooms clean and tidy. Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 16 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): Standards 32, 33, 34, 35 and 36 were inspected on this occasions. Quality in this outcome area is adequate. This judgment had been made using available evidence including a visit to this service. Service Users benefit from a staff team that are competent and effective, the homes recruitment policies and practices are line with requirement. It is the Inspectors opinion that the Service Users individual and joint needs are not met due to current staffing levels, taking into account the present expectation that two staff members are sufficient to cover each shift that will call for a member of staff driving Service Users to and from centers, other activities and appointments leaving another on her own for long periods. EVIDENCE: The Inspector was able to talk with two staff members, the Assistant Manager, the Registered Manager and the Locality Manager during this inspection and was able to view staff records including training records. All involved were able to assure the Inspector that the required recruitment practices were carried out and this was reflected in the staff records examined. Training records indicate that the home offers a full and varied training program that includes Health and Safety, First Aid, basic Food Hygiene, Person Centred Planning, Moving and Handling, personal Awareness, Medication and Protection of Vulnerable Adults. Staff spoken with confirmed that training was offered regularly as was supervision. Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 17 During the previous Inspection and during the two visits made to the home for this one, both the Manager and the Assistant Manager had to absence themselves because of the need to take Service Users to and from the day centre, to appointments or other activities. The Service Users choose what sessions they attend at the day centre, sometimes only attending in the morning or afternoon. This means that the driver can make many journeys to and from the day centre in one day. At present there is a vacancy in the house so there are only seven Service Users, the house is expecting to fill the vacancy soon. The Inspector feels that the staff to Service User ratio is not sufficient to allow one of the staff members to be out of the building for long periods of the shift. With only two staff members on duty, there will inevitably be times when staff are in the home on their own with Service Users and the other will be driving the house vehicle, with Service Users on board, on their own. Neither the needs or the safety of the Service Users can be catered for under these circumstances. Lone working Risk Assessments, that were asked for at the last Inspection, have been done, but the Inspector does not feel they are robust enough as the staff member working alone would be dependent on the ability and calm thinking of a Service User for support in the event of an emergency. A previously restated requirement that the registered person must establish and maintain a system for reviewing and improving the quality of care provided at the care home, in this instance to monitor that sufficient staff are employed to meet the needs of service users has not been done. The Inspector had a discussion with the Registered Manager and the Location Manager during the follow up visit and clearly reiterated her concerns regarding this issue. This requirement will be restated again. It is imperative that this assessment is done within timescales given if the organisation wishes to avoid enforcement on this issue. Please see Requirements 2 It will also be a requirement that the Inspector should be informed of the outcome of the assessment with the reasoning of decisions made. The home must convince the Commission that they are able to supply staff in sufficient numbers or that safeguards have been put in place that will ensure that the safety and wellbeing of the Service Users is protected at all times. Please see Requirements 3 During the previous inspection it was noted that staff members work long hours and routinely worked two sleep-in duties in a row. New guidelines dictate that staff should not do two sleep-in’s together, however inspection of the rota indicates that staff are still often working double shifts, sometimes doing a late shift with a sleepin, an early shift and then continuing into a late shift. The Manager assured the Inspector that staff worked within the European Time Directive and did not exceed 48 hours a week and that the need for staff to work extra hours was due to the staff vacancies, the vacancies have now been filled and people are doing induction training. Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 18 Bearing in mind that staff often work on their own with the Service Users, consideration should be given as to whether it is safe for staff to work long hours without proper rest between shifts. Please see Recommendation 1 Three staff files were examined and evidence was found to show that before a successful candidate starts work two references were taken up, CRB checks are made, proof of identity and evidence of fitness was sought. Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 19 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): Key Standards 37, 38, 39 and 42 were inspected on this occasion. Quality in this outcome area is poor. This judgment had been made using available evidence including a visit to this service. The Service Users benefit from a home that is well run and can be confident that their views underpin the running of the home. Health and Safety safeguards are in place and checks are carried out regularly. Concerns remain regarding risk assessments not being robust enough and not being carried out in key areas. EVIDENCE: The Registered Manager appears to be knowledgeable and able to run the home, she shows a good understanding of the Service Users and their needs and the ethos of the house is obviously geared toward empowering the Service User. The home is organised and the Service Users benefit from the calm and supportive atmosphere generated by the Manager and staff. Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 20 During the Inspection the Inspector was able to talk to three Service Users and two of the Service Users parents by telephone. All Service Users, their families and other professionals involved with the home were sent a survey directly from the Commission. The Commission received responses from all the surveys sent to the Service Users, who were assisted by staff to complete them and all of the families responded and one was returned by the homes GP. All the Service Users expressed content with the home and stated that they liked the staff and felt that they treated them in a way they liked. All believed that they were listened to and that their views were important in the running of the home. The GP responded favourably and the parents who responded to the surveys and who spoke with the Inspector also expressed overall satisfaction but there were several comments that the communication between the house and families could be better and one person felt that the families should be consulted when the care plans are updated. One of the larger bedrooms has large French windows and is difficult to keep warm. A free standing electric oil filled heater was being been used to help warm the room. However when examined it was found by the Inspector that the surface became so hot that it was likely to cause serious injury to anyone who was to lean on or fall against the heater. When the Assistant Manager was told of it’s potential dangers she agreed that it was a hazard and removed it from the room immediately and assured the Inspector that it would not be used again. This heater and any of a similar design must be removed from the home to avoid them being used and therefore becoming a hazard to the Service Users. Also it is recommended that ambient temperatures throughout the house are checked and steps are taken to enable the whole house to be heated to an appropriate level that is comfortable to those living in the home, using means that will not become a danger to the Service User. Please see Requirement 4 and Recommendation 2 A sample of Health and Safety records were tested and found to be in order. However the Inspector has concerns regarding the safety of Service Users and staff members in two main areas. The home relies on the use of the house vehicle to get people to and from the day centre, appointments and other activities. It is practice for the Service Users to travel with only the driver and no escort. The Inspector does not consider this to be a safe practise due to the possible needs of the Service Users during the journey and one could become ill or have a seizure. Also in the event of even a minor accident the driver will be unable to deal with the consequences of it and support the Service Users who may be shocked, frightened or injured. A worse scenario could be that the driver is injured and the Service Users are left to tend to themselves. Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 21 The previous Inspection Report required that a risk assessment be done regarding use of the homes’car, this requirement will be restated and it is strongly advised that the risk assessment is done and interventions actioned with due urgency. It is also usual practice for staff members to be left on their own in the house with Service Users. A risk assessment around lone working has been carried out as a requirement from a previous inspection. The outcome is that the Service Users can be trained to call for help if anything untoward should happen to the staff member. The Inspector can foresee problems with this plan. It presupposes that the Service User is able to assist and is willing. If the difficulties arise because of challenging behaviour this may not be the case. Nor has account has been taken of the fact that the Service User may be frightened or panicked and will therefore be in no fit state to plan what to do in an emergency. Any lone working policy cannot be generic to all staff, people have different abilities and some may have medical conditions that make it unwise for them to be left to work alone with vulnerable people. The lone working risk assessment must be reassessed. Please see Requirement 5 Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 1 1 1 X Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 23 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 Standard YA22 Regulation 22 Requirement The registered Manager will keep the Inspector Informed of the progress and outcome of the complaint that is ongoing at present. The registered person must establish and maintain a system for reviewing and improving the quality of care provided at the care home (in this instance regarding the needs of the Service Users and whether the present staffing ratio is sufficient to meet their needs and to keep them safe) The Registered Manager will inform the Inspector of the outcomes the risk assessment and decisions made regarding the needs of the Service Users and whether the present staffing ratio is sufficient to meet their needs and to keep them safe. The registered Manager will ensure that any heating in the home is supplied by a means that is safe and will not cause injury to the service users. Timescale for action 16/08/06 2 YA33 18(a) 16/08/06 3 YA33 18(a) 16/08/06 4 YA42 13(4c) 16/08/06 Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 24 5 YA9 13(4c) The Registered Manager must ensure that the Lone Working Risk Assessment is reassessed to safeguard service users (and staff) when staff are working alone in the home with service users. 16/08/06 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 YA33 Good Practice Recommendations Consideration should be given to limiting hours that can be worked by any individually, particularly in relation to people having the opportunity to rest properly between shifts. It is recommended that ambient temperatures throughout the house are checked and steps are taken to enable the house to be heated to an appropriate level that is comfortable to those living in the home, using means that will not create a danger to the Service User. 2 YA24 Old Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Manse The DS0000006970.V292221.R01.S.doc Version 5.1 Page 26 - 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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