Inspection on 26/02/07 for One-Six-One

This inspection was carried out on 26th February 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 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

One-Six-One 24/09/07

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 Mrs Lella Andrews Unannounced Inspection 26th February 2007 09:30 One-Six-One DS0000027509.V332170.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.V332170.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.V332170.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 Mr Andrew Orford Care Home 8 Category(ies) of Learning disability (8) registration, with number of places One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th August 2006 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. One-Six-One DS0000027509.V332170.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 about the Home that has been gathered since the last Inspection which includes a random inspection (Nov 06) and an unannounced visit to the Home by two Inspectors on the 26th February 2007. During the visit the Inspector was shown around the communal areas of the Home, spoke to clients and staff, looked at records and spent time discussing issues with the management team. Feedback following the Inspection was provided to the management team at a separate meeting three days after the visit to the Home. The report also includes information gathered from comment cards completed by clients (5), relatives (2) and a health professional. Information from the comment cards include the following: “the food and staff” – (good things about the Home) – client “have a laugh” – client “have my own space” – client “not kept informed of important issues” – relative “some staff are good and communicate well” – relative “…listen if you make a complaint” – relative “usually get enough information about important issues” - relative “enough staff on duty” – relative “staff seek advice and act on it” – health professional The Home next door which is also owned by the company was also inspected at this time. In general, the Home has made improvements in lots of areas since the last key inspection. They have been assisted to do so by the appointment of a consultant. These improvements need to be maintained and further areas of development identified so that the Home continues to improve. There is an ongoing investigation into an allegation of abuse made by one of the service users. What the service does well: The Home provides attractive and comfortable accommodation for the clients and has an ongoing maintenance and redecoration programme. The clients are supported to take part in a range of activities and to access local facilities. One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 Page 6 The care plans contain good information about the clients needs. The clients enjoy their meals and are offered choices. Clients like the staff and said that they are friendly and helpful. 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.V332170.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.V332170.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): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Home has appropriate procedures for the assessment and admission of a new client. EVIDENCE: The Home has not admitted any new clients for over a year although one client moved back to the Home recently after a few months away. The Home has appropriate procedures in place for the assessment and admission of prospective clients. One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 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. 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. The care plans and risk assessments now contain improved information for staff about how to meet the clients needs. The clients are supported to make their own decisions in range of daily living situations. EVIDENCE: A sample of care plans were seen. These have been improved and contain more detailed information about the needs of the clients and how these should be met. They would benefit from further detail about the action staff should take if the use of physical restraint is not successful. The comment cards indicate that the clients are aware that they have a care plan. One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 Page 10 Additional risk assessments have also been completed, particular with regard to clients behaviour and the use of physical restraint. These would benefit from being more detailed consideration of the risks of using physical intervention rather than merely the risks of not using it. The care plans and risk assessments need to maintained, reviewed on a regular basis to identify any change in need and updated as necessary. The staff who spoke to the Inspectors were aware of the care plans and new members of staff said that they have discussed these within their induction and been given time to read them. One of the clients has an independent advocate. Some of the clients have relatives who are very involved in their care. One of the relatives comment card states that they feel that they are not kept informed of important issues affecting their relative and one states that they are “sometimes” kept informed. The staff gave examples of how the clients are offered choices and supported to make their own decisions on a daily basis. Staff were seen to offer choice. There are situations in which the clients are not able to make their own decisions or those decisions are not able to be responded to in the way in which they may like. These situations and the reasons for this are starting to be recorded within the care plans which is an improvement. This needs to be continued and further developed. One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 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. Clients enjoy their meals and are offered choice with regard to meals and drinks. One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 Page 12 EVIDENCE: The clients comment cards all, except for one, state that there are lots of things for them to do with additional comments made such as “plenty to do”. The relatives comment cards were mixed with one stating that there is often not enough staff for clients to go out and socialise and the other indicating that the clients do have plenty to do. Two of the clients have two members of staff each to support them away from the Home for the majority of the waking day, seven days per week. The Inspectors did not speak to either of these clients, nor observe staff working with them and so are unable to comment on the quality of their support at those times. Two of the clients attend formal day services during the week and the staff at the Home support the other two clients during the day. Discussions with clients and staff and a look at the records show that the clients are supported to access a range of leisure activities such as shopping, meals out, visits to local places of interest, cinema. The care plans contain information about how the clients like to spend their days. The Home has several 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 (also owned by the company). 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 clients are supported to have a holiday if that is what they would like to do. These are arranged in small groups or individually, depending on the individual client. The Proprietors home in Spain has been used for some clients to have a holiday but there have been some concerns about the staffing support at these times and so this practice has stopped. The care plans contain information about the arrangements in place for supporting clients to maintain contact with relatives. As previously mentioned, one comment card indicated that staff do not keep in touch satisfactorarily whilst the other indicates that this does usually happen but that they would welcome additional contact with the Manager of the Home. One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 Page 13 The Home has a cook who prepares the main meal for the evening. She is also responsible for ordering and purchasing food as well as preparing menus. The clients said that they enjoy their meals and that they can always have an alternative to what is on the menu. They said that the cook knows them well and that she knows what they like. 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.V332170.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 and 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. There is a need for some improvements to be made to the medication system to make it safer. EVIDENCE: The information in the care plans about the health and personal care needs of the clients has improved. This needs to be maintained and regularly reviewed and updated as necessary. The care plans show that the clients are supported to attend appointments for general health care such as GP, dentist and optician as well as more specialised health care such as psychiatrists. One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 Page 15 The health professional who completed a comment card visits one of the clients with regard to a specific health need. Their comment card indicates that the staff work well with them, that they meet the needs of the client in this respect and that guidance is incorporated into the care plan. 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 support that clients need varies. The medication system was inspected. An additional communication book is kept for staff to record any changes to medication. This is good practice and enables staff to keep up to date more easily. The Home has appropriate procedures relating to medication and staff receive appropriate training. It is recommended that records are kept of the supervision of staff administering medication during their induction. There are some areas in which the system could be improved and the following requirements are made about these: It is required that: the medication administration records are maintained and up to date accurate records are kept so that an audit can be carried out for each medication there are clear records with regard to PRN (as required) medication and those with variable dose. It was noted that the lock on the medication cupboard would benefit from additional security although this was not considered to be a serious risk. The Manager said that he had addressed this at the end of the visit. One-Six-One DS0000027509.V332170.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 and 23 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Relatives and clients said that they are aware of who to complain to. Procedures relating to the clients money have improved. Staff have attended training with regard to Safeguarding Adults and so have a better understanding of abuse and when to report concerns. EVIDENCE: The relatives comment cards both state that they are aware of the complaints procedure and that the staff do listen if they raise any concerns. The Manager sent a copy of the procedure to all relatives following the last inspection. The clients comment cards all stated that they know who to talk to if they are unhappy about anything. The majority of the staff have recently attended Safeguarding Adults training and additional training has been booked for those who have not yet done so. New staff said that they had received this training within their induction. The staff who spoke to the Inspectors were clear about their responsibility to report concerns and aware of the whistle blowing policy. One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 Page 17 All of the staff have attended training with regard to the use of physical interventions/restraint. New staff attended this during their recent induction. The care plans are now clearer about the use of physical interventions with clients and about their individual behaviour and the need to try alternative ways of supporting them before any physical intervention is used. It is recommended, however, that the planning for the use of physical interventions is a multi agency approach eg. Involving social workers etc, and that the care plans reflect this. Following the last key inspection the requirements made about the need for improved policies relating to the looking after of clients money and of the additional charges that the clients are liable for have been met. The care plans include a financial care plan including details of how the clients money is looked after and how they are supported to make purchases. The team meeting minutes show that issues relating to the correct procedure for looking after clients money have been discussed with the staff. A sample of financial records were seen and these show improvements since the last key inspection. However, it was noted that receipts for expenditure on behalf of one of the clients actually included expenditure for staff beverages and also household items. The Manager said that he would address this immediately and reimburse the client. This took place several months ago and it is required that the Manager ensures that this situation is reviewed for all clients to ensure that they have not been paid for items they are not responsible for. A concern has been raised in the last few months about the lack of female staff support provided to a female client who went on holiday to the directors villa in Spain last year. The Manager and Directors said that a female member of staff should have supported the client but had been unable to at very short notice and that the only member of staff available who had the appropriate training was male. This meant that the female client was supported by a male member of staff with a male friend of the Directors providing assistance with driving. The male Director was also staying at the villa although the Manager said that he was staying in an annexe of the Villa. Staff confirmed that the client does not require assistance with personal care but this situation is still not satisfactory. In 2006 an allegation of abuse was made by one of the clients. The Criminal Prosecution Service decided against prosecution and the Commission are currently in the process of undertaking their own investigation and considering appropriate enforcement action to take, if any. A selection of staff files were seen during the visit and it was noted that there is a high level of staff (at least 6) employed with criminal records. The One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 Page 18 convictions are varied and the length of time elapsed also varies. The Manager said that he discusses the situation with staff prior to employing them and does consider the risks associated with employment. There is an appropriate procedure with regard to this situation. However, there are no records of the detail of these discussions and the seriousness of some of the convictions are of concern to the Commission. It is required that a record is kept of the discussions with staff and that an effective risk assessment is carried out prior to appointing a member of staff who has criminal convictions. One-Six-One DS0000027509.V332170.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 provides a good standard of accommodation for the clients. EVIDENCE: The Home is attractively decorated and furnished. There has recently been a water leak which has been addressed and the Manager said that the redecoration to the ceiling will take place shortly. The clients comment cards state that they are able to keep their things private and additional comments were made about the bedrooms in the section that asks what is good about the Home. One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 Page 20 The Directors of the company have a maintenance and redecoration plan and work is continually carried out to improve the standard of the accommodation. In recent months the kitchen has been refurbished, the hallway decorated and carpets have been replaced in bedrooms. One-Six-One DS0000027509.V332170.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 standard and effectiveness of the staff induction and training has greatly improved so that staff feel more confident and able to undertake their roles more effectively. Improvements needs to be made to the recruitment system so as to provide better protection to the clients. EVIDENCE: The Home has greatly improved the induction and training provided to staff. Several new staff were recruited in January 2007 and those that spoke to the Inspectors said that they have received effective induction and support since starting work. The company has employed a consultant who is currently providing the induction and some ongoing training. One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 Page 22 The Manager provided information stating that one member of staff has completed NVQ Level 2 and two have completed Level 3. The majority of the rest of the staff team are enrolled for either Level 2 or 3. Staff have received training in a range of mandatory subjects recently and said that they have enjoyed it and that it has been relevant to their role. As previously mentioned there is one member of staff who has yet to attend training with regard to the use of physical interventions. Staff also said that they are receiving regular supervision and have recently had appraisals. New members of staff said that they feel well supported by the staff team and that there is always more experienced staff on duty who they can go to for assistance if needed. Regular staff meetings have started to take place which enables the staff to discuss relevant issues and to ask questions. The clients comment cards all, except for one, state that they feel well cared for and that the staff help them. Two listed “staff” when asked what is good about the Home. The relatives comment cards are mixed with one stating that not all staff have the right skills and experience, thereby increasing the incidents of difficult behaviours and one stating that the staff do have the necessary skills and experience. The health professionals comment card states that the staff have the right skills and experience and that staff communicate well with them. Observations of staff show that staff speak kindly and respectfully to the clients and that they genuinely appear to enjoy supporting the clients. The staffing rotas were seen and these are now, in general, accurate and so this requirement has been met. The Manager needs to remember to record his hours on the duty rota when he is working directly with clients as part of the staffing rota. The Home has recruitment procedures and, in general, these are effective. However, the Commission has concerns about the issue of employing staff with criminal records, (see previously in this report) and also one of the files sampled only had one reference. It is required that the information listed in Schedule Two is kept for all members of staff. One-Six-One DS0000027509.V332170.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. There have been improvements to the management of the Home so that staff now feel that they are more involved and kept better informed about issues affecting the Home. The Home has completed its first quality assurance report and so have started to consider more effectively the quality of the service that they provide. Staff are receiving more regular and appropriate training with regard to health and safety issues. One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 Page 24 EVIDENCE: The company has three Directors, one of whom is the Registered Manager of the Home. The other two Directors have very little, if any, direct involvement with the clients at the Home. Since the last key inspection the company have appointed the services of a consultant to assist with making improvements to the service provided at the Home. The Home has a deputy manager who works in the Home full time. Staff and clients said that they view the Manager and the deputy manager as taking equal responsibility for managing the Home but that they see the deputy manager more often as she spends more time in the Home. The company has an office close by where the Manager spends some of his time. The Manager has not yet completed NVQ Level 4. Improvements have been made to the management style within the Home with staff feeling that they are included more in decision making and are kept better informed about what is happening within the Home. They said that the on call system is effective and that there is always someone available for support and advice. Monthly visits are being carried out by the consultant and reports sent to the Commission as per Regulation 26. The Home have recently carried out their own internal quality assurance process which involved sending questionnaires to clients, relatives and visiting professionals. The results of this have been collated into a report. This methods of continually reviewing the service that they are providing is positive and a process which should enable the management team to plan for further improvements. A selection of health and safety records were seen at the random inspection in November 2006 and found to be up to date so these were not seen again at this visit. Training records show that staff have attended, or are booked to attend, training in a range of health and safety issues such as Food Hygiene, Moving and Handling, Fire Safety and Health and Safety. There are still some concerns about the health and safety of the clients and these are detailed previously in this report. One-Six-One DS0000027509.V332170.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 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 1 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 X 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X X 2 3 X X 3 X One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 Page 26 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 YA23 Regulation 13 (6) Requirement It is required that all staff receives formal training about the protection of vulnerable adults. The previous date of 31/12/06 was not met It is required that the Medication Administration Records are kept up to date. It is required that clear records are kept for all medication so that effective audits can be carried out. It is required that guidance is available for staff with regard to the use of PRN medication and those with a variable dose. It is required that the Manager reviews all of the clients financial records to ensure that they have not paid for items that they are not responsible for. It is required that effective risk assessment is carried out with regard to employing staff who have criminal convictions and that a written record is kept of this. Timescale for action 30/04/07 2 3 YA20 YA20 13 (2) 13 (2) 26/02/07 26/02/07 4 YA20 13 (2) 31/03/07 5 YA23 13 (6) 30/04/07 6 YA34 13 (6) 20/03/07 One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 Page 27 7 YA34 19 It is required that the information listed in Schedule Two of the Care Homes Regulations is kept for all members of staff. 26/02/07 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 Refer to Standard YA20 YA23 Good Practice Recommendations It is recommended that a record is kept of staff being supervised to administer medication as part of their induction records It is recommended that the care plans contain evidence of multi agency discussions and agreement about the use of physical interventions One-Six-One DS0000027509.V332170.R01.S.doc Version 5.2 Page 28 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.V332170.R01.S.doc Version 5.2 Page 29 - 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!