Inspection on 22/01/07 for Pinewood

This inspection was carried out on 22nd January 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pinewood 21/06/07

Pinewood 18/01/06

Pinewood 02/08/05

Pinewood 23/11/04

Pinewood 20/05/04

Pinewood 08/12/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Pinewood 101 Pinewood Avenue Crowthorne Berks RG45 6RQ Lead Inspector Jill Chapman Unannounced Inspection 22nd January 2007 10:30 DS0000050231.V325011.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 DS0000050231.V325011.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. DS0000050231.V325011.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinewood Address 101 Pinewood Avenue Crowthorne Berks RG45 6RQ 01344 773139 01344 752833 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.new-support.org.uk New Support Options Limited Mrs Lucy Muriel Dexter-Elisha Care Home 4 Category(ies) of Learning disability (4) registration, with number of places DS0000050231.V325011.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2006 Brief Description of the Service: The home is a detached 2-storey house situated in a residential area close to the Crowthorne village centre. The village has shops, pubs and local community resources. There is an accessible garden that has been equipped for wheelchairs. The house has a large lounge diner, kitchen and laundry. The service users bedrooms are all single and on the ground floor. There are assisted bathing facilities to help service users with restricted mobility. The current fees for the home are £1,407.99 per week. DS0000050231.V325011.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 10.30 and was in the service for 5 hours 30 minutes. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector toured the communal areas of the home and service users bedrooms. Discussion took place with two Senior Support Workers and one Support Worker. An Area Manager visited during the inspection and was also consulted by telephone later in the day. Records relating to Health and safety, staff training and service users care records were sampled. All four service users were at home during the inspection and some were able to give their views about the care they receive. What the service does well: The home makes sure it can meet service users needs before they are admitted. Service users get the chance to try out the home before deciding to live there. Service users care needs are met and are regularily reviewed. The home would be able to meet diverse cultural and care needs if necessary. Potential risks for service users are identified and steps taken to reduce the risks. Service users are happy with the care provided and care practice observed was appropriate. Feedback about the service from other professionals involved in service users care was positive. Service users benefit from structured day services and paid supported employment.They are helped to keep in touch with their families and friends. Service users are encouraged to be as independent as possible and their privacy and dignity is respected. DS0000050231.V325011.R01.S.doc Version 5.2 Page 6 Service users benefit from a balanced and healthy diet. They receive personal care in the way they prefer and their health needs are met. They are supported to take their medication safely. There are systems in place to deal with service users complaints and to protect them from potential abuse. Service users know who to talk to if they have a concern and that their money is kept safe. Service users benefit from a homely and well cared for home. The home is kept clean and hygenic. Service users are supported by a staff team who can communicate well with them and who know how to meet their needs. There are more staff on shift to meet service users needs. The organisation is good at seeking service users views to help develop the service. Health and safety systems are mostly good. What has improved since the last inspection? What they could do better: The opportunities for planned community access and individual activities need further development. The manager should make sure that current staff deployment can meet service users activity and community access needs. The lack of authorised drivers contributes to this problem. An occasion where food and money ran low needs investigating to make sure there are adequate supplies and money to meet service users needs. Medication training needs updating and an issue regarding medication storage needs investigating to make sure it is stored safely. Previous requirements regarding staff training on Complaints and the Protection of Vulnerable Adults need to be carried out to keep staff up to date. The funding and choice for purchasing new service users lounge chairs needs to be reviewed to make sure service users rights are upheld. A requirement to replace the kitchen cupboards and flooring has been outstanding since November 2005. DS0000050231.V325011.R01.S.doc Version 5.2 Page 7 A previous requirement to update staff training on infection control needs to be carried out . Other essential staff training needs to be kept up to date. Some improvements are needed to make sure that the home is consistently managed and that delegated tasks are carried out properly to maintain a safe environment for service users. Improvements in maintaining fire safety are needed. Legal requirements should be carried out in the given timescales. 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. DS0000050231.V325011.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000050231.V325011.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home makes sure it can meet service users needs before they are admitted. Service users get the chance to try out the home before deciding to live there. EVIDENCE: There have been two new service users admitted since the last inspection. The records for both showed that they received a full care management assessment prior to admission. A service user confirmed that he had received information about the home prior to admission and had visited the home prior to admission to see if he liked it. DS0000050231.V325011.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 good. This judgement has been made using available evidence including a visit to this service. Service users care needs are met and are regularily reviewed. Service users are happy with the care provided and care practice observed was appropriate. Feedback about the service from other professionals involved in service users care was positive. Potential risks for service users are identified and steps taken to reduce the risks. EVIDENCE: The files of three service users were sampled and show that care plans are deveoped from the assessment of need and that these are reviewed regularly. Care plans cover a variety of relevant needs including communication, behaviour, mobility and personal care. Daily diaries evidence day to day care carried out. Service users were happy with the care provided and care practice observed was appropriate. Feedback about the service from other professionals involved in service users care was positive. DS0000050231.V325011.R01.S.doc Version 5.2 Page 11 Reviews are held with service users, family and other professional involved in their care. There were post placement reviews on file for two new service users to make sure that the placement was still meeting their needs. An annual review was seen for a long standing service user. A service user confirmed his involvement in decisions about his care. Records show that service users are supported to make decisions about their daily routines and any limitations on choice is supported by risk assessment. It was observed that service users are routinely encouraged to make day to day choices. Service users records show that there are a variety of appropriate individual risk assessments in place. These identify any potential risks and show clearly how these can be reduced. DS0000050231.V325011.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, 14,15, 16 & 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from structured day services and paid supported employment. The opportunities for planned community access and individual activities need further development. Service users are helped to keep in touch with families and friends. Service users are encouraged to be as independent as possible and their privacy and dignity is respected. Service users benefit from a balanced and healthy diet. An occasion where food and money ran low needs investigating to make sure service users needs can be fully met. EVIDENCE: Service users are supported to take part in formal day services programmes and two service users have paid employment at a local supermarket. One service user described his work and said he enjoys this. Staff are involved in transporting servivce users to their employment. DS0000050231.V325011.R01.S.doc Version 5.2 Page 13 Staff said that service users community access has improved but is still limited and reliant on spontaneaous rather than planned opportunities. Staff views varied on the reasons for this, some believing that there are still not enough staff for the needs of the service users and others thinking that better access could be achieved if staff worked more flexibly. The home has a vehicle with wheelchair access but staff said it is not large enough for all service users to go out at the same time which prevents them going out as a group. Information sent from the manager shows that a lack of authorised drivers cotributes to the difficulty in taking service users out. On the assessment document for a new service user it was highlighted that since 1997 he regularily attends a local church every Sunday which he enjoys. This need has not been transferred to his current care plan and he has not attended since being in the home. Staff said that plans were being made to provide staff to support him to attend church but this was not shown in records seen. The service are no specific cultural or dietry needs but the home has met these in the past. A previous requirement to develop individual activity plans has not been met and is outstanding from the last two inspections. Each service user has a Activity Timetable but these only show their Day Services provision. Daily diaries and the handover record show any spontaneous activities but it is difficult to track these to see if they have improved. The recording format of these has not been reviewed as recommended in the last report. In past years service users have had an annual holiday but staff said that this year they have had day trips because there were not enough staff to take them away. It was clear that the home helps service users to maintain relationships with families and friends. Their important contacts are written in their files and family visits are recorded. Staff were observed to help service users be as independant as possible and it was clear from observation that service users are treated with respect. Staff relate well to service users and they help them maintain a dignified appearance. Ensuite toilets have provide more privacy for two service users. Service users mail is opened in their prescence and assistance given when necessary. Service users can choose to spend time in their rooms or to sit with others in the lounge. Service users said they like the food provided and they help choose the menus. Menus show that a balanced diet is provided. The shopping was carried out the inspection day and food stocks were good. It was was seen recorded in the communication book is that foodstocks recently ran low one weekend and there was insufficient food and petty cash for the next shift to purchase this. DS0000050231.V325011.R01.S.doc Version 5.2 Page 14 This matter was brought to the attention of the Area Manager for further investigation. DS0000050231.V325011.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive personal care in the way they prefer and their health needs are met. Service users are supported to take their medication but a lack of updated staff training and an issue about safe storage of medication needs investigating to improve staff practice. EVIDENCE: There are detailed support plans in place with good evidence to show how service users prefer to be helped. Health care needs are well documented and health appointments are recorded. One service user was taken to a hospital appointment during the morning. A recommendation regarding a stock control system for medication has been carried out. Arrangements for administration and storage of medication were mostly satisfactory. The communications book showed that on one occasion a months supply of medication was left unlocked in the office overnight. This matter was brought to the attention of the area manager. A further shortfall is DS0000050231.V325011.R01.S.doc Version 5.2 Page 16 that although staff have been trained to give medication in the past, records show that refesher training has not been given since 2004/05. DS0000050231.V325011.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are systems in place to deal with service users complaints and to protect them from potential abuse. Service users know that their money is kept safe. There are unmet requirements to update staff training in Complaints and the Protection of Vulnerable Adults. EVIDENCE: The Commission has received no information from service users or their relatives about complaints against the service. The home has a complaints procedure and records show that the home deals properly with any complaints received. Service users said they know who to talk to if they have a concern. There is an unmet requirement from the last inspection that staff receive refresher training on how to deal with complaints. The home has a policy on how to protect service users from potential abuse and to encourage staff to report poor care practce. It was seen that suitable steps are taken to investigate any concerns. There is a secure system for storing service users money and valuables, Service users money is checked twice daily by two staff to ensure accuracy. This was seen and was accurate. Records show that staff have last received Protection of Vulnerable Adults training in 2003. There is an unmet requirement to provide staff with updated training. DS0000050231.V325011.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 adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a clean and well cared for home. Recent works have improved the environment for service users and kitchen improvements are planned. The funding and choice for purchasing new service users lounge chairs needs to be reviewed to make sure service users rights are upheld. A requirement to update staff training on infection control needs to be carried out . EVIDENCE: The home was warm and well looked after. Service users bedrooms are personalised to their own taste. One service user showed the inspector his new bedroom furniture and service users spoken with were happy with their accomodation. DS0000050231.V325011.R01.S.doc Version 5.2 Page 19 Requirements from the last inspection to carry out redecoration, to repair a chipped bath, carry out work to the electrical wiring and fuse box have been carried out. A requirement to replace the kitchen cupboards and floor has been outstanding since November 2005. Work needed to overhead tracking for a hoist has not been carried out because the service users is no longer in the home. A large gazebo has been errected in the garden to enable the service users to enjoy the garden in the summer months. At the time of the inspection contractors visited the home to help service users choose their own new chair for the lounge. It was said by staff that service users were to pay for their own chair but that the manager had asked for a certain type of chair to be ordered, this is not acceptable because the home is expected to provide furniture that is fit for purpose. This type of chair did not appear suitable or comfortable for individual service users and they had their own view about which chair they liked and felt comfortable in. Staff showed that the current lounge sofas whilst relatively new have deteriorated and are not suitable for the service users. This matter was brought to the attention of the Area Manager who agreed it was not acceptable and said she would look into the issues of funding and choice. It was later confirmed by the manager that service users would be able to choose their own chairs and that the organisation would pay the basic price for the standard chair with service users paying a contribution if they choose a higher specification. The home was found to be clean and hygenic but there is an outstanding requirement for staff to have refresher training on infection control. DS0000050231.V325011.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by a staff team who can communicate well with them and who know how to meet their needs. There are more staff on shift to meet service users needs but the manager should make sure that staffing current staff deployment can meet service users activity and community access needs. The registered persons should make sure that mandatory staff training is kept up to date and that staff have the opportunity to complete NVQ training. EVIDENCE: Staff were observed to relate well to service users and to understand their communication and needs. They understood service users specific health needs and have guidelines on how to respond to any challenging behaviour. The organisation has a National Vocational Qualification programme in place and the pre inspection checklist shows that only two staff have NVQ level 2 and one staff is taking NVQ 3. DS0000050231.V325011.R01.S.doc Version 5.2 Page 21 A requirement to ensure that there are adequate trained staff on duty to meet the needs of the service users has been mostly met. Staffing levels have increased since the last inspection due to two vacancies being filled. There are now three care staff on daytime shifts and one waking night staff. This level appears to meet the majority of needs but activities and community access need to improve. The manager should ensure that current staff deployment can meet these needs. Due to the increase in service users there are vacant staff hours and these are being advertised. In the meantime vacant shifts are being covered by bank and agency staff. The organisation has a robust recruitment procedure in place and this includes carrying out references and police checks to make sure potential staff are safe to work with vulnerable service users. No new staff have been admitted since the last inspection when this standard was fully met. The organisation provides induction and core training to the required standard. It was found however that the majority of mandatory training for all staff was out of date. These include Food Hygiene, First aid, Medication, Manual handling and Health and Safety. The inspector was told that training profiles are in the process of being updated with a view to booking the training. This was brought to the attention of the Area Manager for urgent attention and medication training updates were booked immediately. An up to date training plan, as recommended from the last inspection, is not in place. DS0000050231.V325011.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The organisation should notify the Commission of the interim management arrangements while the manager is away from the home for over 28 days. Some improvements are needed to make sure that the home is consistently managed and that delegated tasks are carried out properly to maintain a safe environment for service users. The organisation is good at seeking service users views to help develop the service. Health and safety systems are mostly good but some shortfalls potentially put service users at risk. Improvements in maintaining fire safety are needed. DS0000050231.V325011.R01.S.doc Version 5.2 Page 23 The registered persons should ensure that legal requirements are carried out in the given timescales. EVIDENCE: The manager was off sick at the time of the inspection and a Senior Support worker has been delagated to be in charge of the home. With annual leave and sickness the manager has been away from the home for over 28 days. The interim management arrangements should be notified to the Commission in writing as required by regulation and the Area Manager agreed to do this. At the time of the last inspection the manager had started her NVQ level 4 but this is not completed yet. There are a number of unmet requirements and recommendations from the last inspection report. The lack of progress in developing service users individual activity programmes and keeping staff training up to date are also of concern. During the course of the inspection it became clear that some staff have differing views about how aspects of the service should be carried out. The report has already highlighted that some delegated tasks had not been carried out properly putting service users at potential risk. The registered persons should review these issues to ensure the home is managed consistently and safely. The organisation is good at seeking the views of service users and others in helping to develop the service. One service user told of his involvement in a ccmmitee that helps develop the service. A pre inspection checklist shows that arrangements are in place for the maintenance and servicing of equipment in the home. Regular health and safety audits are carried out. The weekly fire safety audit shows that a faulty fire door closure has not been reapired since April 2006 and this is subject to an immediate requirement. A fire drill was last held in May 2006 and the next one is overdue. Two new service users have been admitted since the last drill and so would not be aware of the homes evacuation procedure. The organisation has a contract for six monthly servicing of the fire alarm system but the last service date seen on the Pre Inspection questionnaire was June 2006. DS0000050231.V325011.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 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 2 33 2 34 3 35 2 36 x 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 2 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 1 1 3 x x 2 x DS0000050231.V325011.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA14 Regulation 16(n) Requirement Develop individual activity programmes. Outstanding timescale 2/10/05 The kitchen cupboards and flooring are in need of replacement. Outstanding timescale 2/11/05 Provide refresher training for staff on how to deal with complaints. Outstanding timescale 18/04/06 Provide staff with Vulnerable Adults training. Outstanding timescale 18/04/06 Refresher training on infection control should be provided Outstanding timescale 18/04/06 Medication training needs updating. The registered persons should make sure that Timescale for action 22/03/07 2. YA24 23 22/03/07 3. YA22 22 22/03/07 4. YA23 13(6) 22/03/07 5. YA30 16(2)j 22/03/07 6. 7. YA20 YA35 13(2) 18 (1) (a) ( c ) (ii) 22/03/07 22/04/07 DS0000050231.V325011.R01.S.doc Version 5.2 Page 26 8. 9. YA42 YA42 23 (4)©(1) 23 (e) mandatory staff training is kept up to date. Repair a faulty fire door closure. Carry out regular fire drills to make sure that staff and service users are aware of the evacuation procedure. Fire Alarm servicing should be kept up to date. 05/02/07 22/03/07 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 YA13 YA35 Good Practice Recommendations It is recommended that the recording format of community activities be reviewed. That the manager develops a team-training plan that would make it easier to have an overview of training needs. An occasion where food and money ran low needs investigating to make sure there are adequate supplies to meet service users needs. The funding and choice for purchasing new service users lounge chairs needs to be reviewed to make sure service users rights are upheld. The registered persons should ensure the home is managed consistently and safely. The manager should make sure that current staff deployment can meet service users activity and community access needs. 3 4 5 6 YA17 YA24 YA38 YA14 DS0000050231.V325011.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. 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