Inspection on 24/09/07 for One-Six-One

This inspection was carried out on 24th September 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

One-Six-One 26/02/07

One-Six-One 29/08/06

One-Six-One 11/10/05

One-Six-One 19/04/05

One-Six-One 01/10/04

One-Six-One 16/04/04

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 One-Six-One The House 161 Wootton Road King`s Lynn Norfolk PE30 4DW Lead Inspector Lella Hudson Unannounced Inspection 24th September 2007 09:30 One-Six-One DS0000027509.V352198.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 One-Six-One DS0000027509.V352198.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. One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service One-Six-One Address The House 161 Wootton Road King`s Lynn Norfolk PE30 4DW 01553 673194 01553 674395 onesixone@btopenworld.com 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) One-Six-One Limited Current manager has application for registration pending Care Home 8 Category(ies) of Learning disability (8) registration, with number of places One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th February 2007 Brief Description of the Service: One-Six-One is a care home providing care to eight people with learning disabilities. It is situated in a residential area of Kings Lynn, approximately a mile from the town centre. There are local shops, a library and other amenities within the immediate vicinity of the home. The premises consist of accommodation on three floors accessed by stairs. There are two reception rooms, kitchen, dining area and laundry on the ground floor. Bedrooms are located on ground, first and second floors. The home was extended in the spring of 2002 to provide two further bedrooms and to improve the standard of accommodation to others. The home has patio, decking and garden areas to the rear. The home provides care for ambulant people who may require consistent support for their behavioural needs. Service users access a variety of day activities and services available locally. The home has its own transport. The fees for current service users range from £1000 to £4556. The Home was originally owned by one family and then was registered as being owned by a limited company with the three original family members being the Directors and one also registered as the Manager. In June 2007 a company called CareTech bought the shares to the company and therefore there are new Directors and a new Manager of the service. The current Manager is in the process of applying for registration with CSCI. One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains information gathered about the Home since the last Inspection (February 2007).This includes information within comment cards completed by relatives and clients as well as information gathered during an unannounced visit to the Home on Monday 24th September 2007. The information contained in the comment cards was positive with some suggestions for improvements such as increased physical activities. Some of the comments were as follows: “good family home atmosphere” “adapts to each individual” “good accommodation” “willing to listen and act” During the visit the Inspector was shown around the communal areas of the Home, looked at records and spoke to clients, staff and the Manager. A further visit to the Home was carried out on the 27th September to gather further information from the Manager and Operations Manager and to provide them with feedback from the inspection process. The Home is still owned by OneSixOne Ltd although there has been a share buyout of this company by CareTech. Therefore, the Directors of the company and the Manager are different from those at the time of the last Inspection (February 2007) although the nature of the purchase means that there was no need to apply for a new registration with CSCI. The Manager, Sharon Jones, has previously worked as a registered manager in another Home owned by CareTech and has been at this Home for three months. She is in the process of applying to be registered with CSCI. There are currently only five clients living at the Home. The Home next door, which is also owned by the company, was also inspected at this time. Considering the inevitable changes that have taken place as a result of the change in Directors and Manager the staff have managed to maintain a consistency of service to the clients and to remain positive about their support of the clients. One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last 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. The summary of this inspection report can be made available in other formats on request. One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 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 One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is written information about the service provided in the Home but this needs some alterations to be completely accurate and also needs to be provided in alternative formats to make it easier for the clients to understand. The Home has an admissions procedure but this has not been inspected in practice as no new admissions have taken place. EVIDENCE: The Home has a Statement of Purpose which has been reviewed and updated in light of the changes within the company. There are some minor errors which still need to be addressed to ensure that it provides accurate information for prospective clients and their relatives/representatives. A requirement is made about this. One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 9 The Home has a Statement of Service document which incorporates the clients contract and the Service User Guide. The ones seen by the Inspector have not been personalised for the individual clients and the Manager is aware of the need for this to happen. This document also needs to be made available in a format suitable for the individual clients. A recommendation is made about this. The company has an appropriate admissions procedure which was unable to be inspected in practice as no new admissions have taken place since the last Inspection. One-Six-One DS0000027509.V352198.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The care planning and risk assessment documentation does not provide clear guidance for staff about how to meet the clients needs which means that there is a risk of needs not being met in a consistent way. EVIDENCE: A sample of care plans and risk assessments were seen. CareTechs corporate formats have been introduced for these and information from the previous care plans and risk assessments has been transferred. The quality of the care plans and risk assessments has deteriorated as the corporate formats are not detailed or specific to individuals. One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 11 There are also areas that are highlighted as risks for individuals but there are no risk assessments available. This means that there is little detailed guidance for staff about how to meet individuals needs or how to effectively manage risks in a consistent way. Although the staff team have worked at the Home for some time and know the clients well there have recently been some changes to the needs of at least one of the clients and therefore there is even more reason for the staff to have detailed guidance. For example, some interim guidance has been written for one of the clients with regard to a recent change in behaviour. However, the risk assessment fails to refer to this guidance and the care plan does not provide detailed guidance to staff about how to manage this behaviour in a consistent way. The daily notes seen which refer to incidents involving the client indicate that the interim guidance was not followed but with no reasons recorded for this. Requirements are made about the need to improve the care plans and risk assessments. Two of the staff have recently attended Person Centred Planning training and have started to talk to the clients about this process. The staff are enthusiastic about this and feel that it is a positive way of ensuring that the views of the clients are at the centre of the care planning process. The nature of this process is that it can take some time and it therefore cannot replace the need to ensure that the care plans and risk assessments are improved. The staff gave examples of how the clients are offered choices and supported to make their own decisions on a daily basis. The Manager said that she intends to implement regular house meetings where the clients can discuss a range of issues within the Home. There are situations in which the clients are not able to make their own decisions, or where there are restrictions on individuals choices, and the care plans need to include information about these issues. One-Six-One DS0000027509.V352198.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, ,16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Clients are supported to take part in a range of formal and more informal activities. Clients are supported to maintain contact with relatives. EVIDENCE: The three completed clients comment cards all state that there are good activities arranged at the Home. One of the relatives comment cards states that they would like to see more physical activities arranged for their relative. The staff said that they have taken note of this and are in the process of looking for appropriate activities. One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 13 One of the clients told the Inspector that there are not enough activities for him to do and that he has told the staff about this. The Manager said that they have made plans to enable the client to be supported to access more activities within the community. Records seen confirm that this is taking place. Two of the clients attend formal day services on a daily basis away from the Home. Two of the clients receive individualised support from staff (each have 2 staff with the) seven days per week from morning until the evening. This support is mainly away from the Home as they use two other properties that the company own which are located close by. The Inspector did not observe the support provided to these two clients. Discussions with staff and clients show that the clients are supported to access a range of leisure activities, such as shopping, meals out, pub visits and holidays. The Home has cars which are for staff to use to provide transport for the clients that live at this Home and those who live at the Home next door. The Home is situated close to local shops, library, pubs and the town centre. The daily routines of the Home are centred around the needs of the clients. For some clients this means that there is a lot of flexibility around when they get up and how they spend their time, whilst for others, there is less flexibility and staff are aware of the need for adherence to agreed times for routines to take place. The care plans do not contain detailed information about the arrangements in place for enabling the clients to keep in contact with relatives. The relatives comment cards state that the staff are good at keeping in contact with them and that they are informed about issues affecting their relative. One of the relatives comment cards particularly mentioned the staffs sensitivity when supporting the client during a difficult time for their family. At the time of the visit one of the clients was away with relatives and another was being picked up by staff following a stay with relatives. The Home has a cook who prepares the main meal for the evening. She has been responsible for ordering and purchasing food as well as preparing menus but currently a review of these processes is being carried out. The cook knows the clients well and the clients say that she knows what they like and that they are always able to have an alternative. The Manager said that once the house meetings start then the clients will have more input into the menu planning. Depending on the risks, the clients are able to use the kitchen and are also able to have drink making facilities in their bedroom. One-Six-One DS0000027509.V352198.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the clients are met but improvements to the care planning system will ensure that staff are clear about how to meet these needs in a consistent way. EVIDENCE: At the last Inspection it was noted that the information about the health and personal care needs of the clients had improved and that this needed to be maintained and regularly reviewed. The new format of the care plans being used means that this information is now less clear and detailed. Health Action Plans have been obtained for the clients but these have not been completed yet. The Manager is aware that the written information about the clients needs must be improved so that the staff have clear guidance. One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 15 The Manager is in the process of meeting the health/social care professionals who are involved in the clients lives. She arranged a meeting to discuss the changing needs of one of the clients and the outcome of this has been written up. One of the clients has diabetes and according to the training record many of the staff have not had recent training about this health need. It is required that this training is provided to all staff. There are always male and female staff on duty so that clients are able to be supported with personal care by staff of the same gender. The clients comment cards state that the staff respect their privacy and that they feel well cared for by the staff. Staff were observed to support the clients in a respectful and friendly manner. Staff knock on doors prior to entering bedrooms and clients are able to have a key to their bedrooms if they wish to have one. The medication system was looked at. Records are kept of medication received into the Home and of the administration of medication. The lock on the medication cupboard has been replaced since the last Inspection and provides increased security. Two of the three requirements made at the last Inspection about medication have been met but the PRN (as required) guidance is still not detailed and so this requirement is repeated in this report. It is also recommended that two people are involved in checking medication that is taken away from the Home eg. When clients go on holiday. The new medication procedure was looked at and this needs to be reviewed and some issues need to be clarified. A requirement is made about this. One-Six-One DS0000027509.V352198.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Relatives and clients said that they know who to complain to and that they are listened to. Staff have attended training with regard to Safeguarding Adults and so have a better understanding of their responsibilities to report any concerns. Improvements in care planning and risk assessments will provide better guidance for staff to ensure that they can meet the clients needs in a consistent way, particularly with regard to challenging behaviours. EVIDENCE: The relatives comment cards state that they are aware of the complaints procedure and that the staff listen to them and consider their views. The clients comment cards state that the staff listen and that they know who to talk to if they are not happy about something. The Home has a new complaints procedure which is the corporate version. There is also a simpler version which may be easier for the clients to understand. One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 17 Records show that all staff, except for one, have attended training with regard to Safeguarding Adults. This member of staff is booked to attend the training shortly. The staff who spoke to the Inspector, including the Manager, are aware of their responsibilities with regard to concerns about possible abuse. The company are in the process of changing the procedure for supporting the clients with their money and so this was not looked at during this Inspection. As previously mentioned, the care plans and risk assessments need to be improved and this is particularly relevant to issues relating to the management of behaviour and to the use of physical interventions. Previously, staff had all attended the same training about the use of physical interventions and the care plans were based on this. However, the company are now using a different training for this issue and so it is important to ensure that a consistent approach is being used by staff. One-Six-One DS0000027509.V352198.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Home provides a good standard of accommodation for the clients EVIDENCE: The Home is attractively decorated and furnished and there has been an ongoing programme of redecoration and refurbishment. One of the relatives comment cards mentions problems with the plumbing and the Manager explained that there have been problems with the showers and that this work is planned to take place this week. The clients comment cards state that the staff respect their privacy. Clients are able to have keys to their bedrooms if they wish to. One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 19 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, 33, 34, 35 and 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff receive appropriate training and support to carry out their roles effectively. EVIDENCE: The induction and training provided to staff has greatly improved over the last year and staff said that they have received effective induction which has helped them to carry out their roles. The Manager said that there will be changes in the provision of training as CareTech have their own training department. Some staff have already attended some training provided by CareTech and said that it was enjoyable and relevant to their roles. As previously mentioned in this report there is a requirement made for all staff to have attended training about diabetes. One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 20 Currently this training is provided in Cambridge and so staff have to travel but the Manager said that there are plans to provide some of the training more locally. There is a need to ensure that all staff are receiving consistent information whilst there is a change in the training providers, particularly with regard to training about the use of physical interventions. The majority of the staff team have achieved NVQ Level 2 or are working towards this. The deputy manager has achieved NVQ Level 3 in management. The rotas show that there are two staff on duty in the morning and three in the afternoon/evening in addition to the individualised support that two of the clients receive. There is also a sleep in member of staff at night. Staff confirmed that this is the usual staffing ratios. Currently one of the clients is needing more support at night time and the Manager is aware of the need to continually monitor this situation to ensure that a sleep in staff is the right level of staffing to meet the needs of the clients at night. The clients comment cards all state that the staff listen to them and that they are kind and supportive. The relatives comment card states that the staff have the right skills and experience. Staff were observed to support the clients in a kind and friendly way. There are clearly good relationships between staff and clients. Considering the amount of change that has taken place within the Home in the last three months the staff, and clients, appear to have adapted very well and are, in general, positive about the future for the Home. At the last Inspection a requirement was made for the necessary recruitment information to be kept as a minor omission had been noted. All of the recruitment files have been sent to the HR department of CareTech to be reviewed. All of the relevant information required by regulation is now held at the Head Office with proformas confirming receipt of this information held at the service. Therefore, the recruitment files were not able to be seen during this visit but the Performance Regulation Manager (CSCI) who liases with CareTech is due to visit their Head Office in November 2007 to sample the recruitment files. The requirement is not repeated in this report but will be commented on within the next report. The Manager has recently started to carry out formal supervisions with staff and records confirm this. One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 21 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, 38, 39 & 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There has been a very recent change in management of the Home which does not seem to have been too unsettling for the clients Appropriate measures are taken to protect the health and safety of the clients and staff. One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 22 EVIDENCE: Previously the company had three Directors, one of whom was also the registered Manager of the Home. A social care consultant had also been employed for the last nine months. Following the share buyout by CareTech none of the three previous Directors are involved with the Home at all. The consultant remained for approximately the first month after the sale but now no longer works at the Home. There was very little handover from the previous Directors. The deputy manager remains in post and initially the Home was managed by CareTechs area manager for the Eastern region. A new manager, Sharon Jones, was appointed to the Home in July 2007. The Manager has previously been a registered Manager of a Home for older people and more recently has been working as a deputy manager at a Home for adults with a learning disability. She is currently working towards the Registered Managers Award. She is also in the process of applying for registration with CSCI. The staff said that they feel that they are well supported and that they have been kept informed of changes that have been implemented. Whilst not every change has been smoothly implemented, in general, the staff seem to have dealt with the changes very well and have remained positive in their support of the clients. At the last Inspection the Home had recently completed their first annual quality assurance process and a report was produced following this. It is expected that this process will be continued and improved upon. Monthly visits, as per Regulation 26, have been carried out and copies are available in the Home. Training records show that staff have attended a range of health and safety training such as food hygiene, moving and handling, fire safety, health and safety. A sample of records relating to health and safety were seen. Although there is a fire risk assessment it is recommended that this is more detailed. One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 23 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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 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 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 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 2 X 2 2 3 X X 3 X One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 24 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. Standard YA1 YA20 Regulation 4 13 (2) Requirement It is required that the information within the Statement of Purpose is accurate It is required that guidance is available for staff with regard to the use of PRN medication and those with a variable dose. The previous date of 31/03/07 was not met It is required that the medication procedure is reviewed and clarified It is required that all staff receive training with regard to diabetes It is required that the care plans contain detailed guidance for staff about how to meet the clients needs It is required that risks are appropriately assessed and that records are kept of this Timescale for action 31/10/07 31/10/07 3. 4. 5. YA20 YA19 YA6 13 (2) 12 15 30/11/07 31/12/07 31/10/07 6. YA9 13 (4) 31/10/07 One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA1 YA20 YA42 Good Practice Recommendations It is recommended that the Service User Guide and contract is available in alternative formats to make it easier for clients to understand It is recommended that two people are involved when checking/signing for medication to be taken away from the Home It is recommended that the fire risk assessment is more detailed One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 One-Six-One DS0000027509.V352198.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!