Inspection on 24/08/06 for Pinfold Lane

This inspection was carried out on 24th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pinfold Lane 16/08/07

Pinfold Lane 06/01/06

Pinfold Lane 08/12/04

Pinfold Lane 03/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Pinfold Lane 1 Pinfold Lane Garforth Leeds West Yorkshire LS25 1HE Lead Inspector Pamela Cunningham Key Unannounced Inspection 24th August 2006 10:30a DS0000001491.V300839.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 DS0000001491.V300839.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. DS0000001491.V300839.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pinfold Lane Address 1 Pinfold Lane Garforth Leeds West Yorkshire LS25 1HE 0113 286 3691 0113 286 3691 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.c-i-c.co.uk. Community Integrated Care Care Home 4 Category(ies) of Learning disability (4) registration, with number of places DS0000001491.V300839.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th January 2006 Brief Description of the Service: Pinfold Lane is located close to the town centre of Garforth. The home was first registered in March 1997, providing care to four men with profound learning disability. The registered provider for the home is C.I.C. (Community Integrated Care) A wheelchair user is accommodated on the ground floor, where the communal sitting areas, kitchen, bathroom, shower and laundry are located. There is a specialist bath lift and hoist in the bathroom. There are two bedrooms on the ground floor and two on the first floor. Three of the bedrooms are double bedrooms. Residents are encouraged to use community facilities in the neighbourhood for social activities. DS0000001491.V300839.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector on 24/08/06 who was at the home for one day, from 10:30am, for six hours. The inspection process consisted of speaking with the proposed manager and support workers. The main purpose of this inspection was to make sure that improvements had been made in the quality of care being provided, and to assess progress on meeting any requirements or recommendations made at the last visit. People receiving care in the home are known as service users, and this is the term that will be used throughout the inspection report. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. The home was seen to be clean, and with no noticeable odours. On arrival at the home, the manager was not on the premises, having gone to do the weekly shopping for the home. During his absence, and until his return, two of the staff on duty participated in the inspection process and made a very valuable contribution. Unfortunately it was only possible to speak with one of the clients, who said he was very happy to be living at the home, liked the food, and was going to his parents’ house for the weekend. Through observation during the inspection it was noticed that the service users’ were happy and appeared content. There were no visitors on the premises during the inspection. What the service does well: Staff spend time with the clients doing things they enjoy. Where it is suitable, this is done on a one to one basis. Staff were seen to be doing this at the time of the inspection. The home continues to receive excellent support from the local healthcare team and there is no problem with asking them to visit the home. All the residents apart from one attend some type of day care. Two of the care staff are working on NVQ level 2, and the remaining 4 are booked on the course. All but one of the care staff have received training on how to handle medication. DS0000001491.V300839.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: • • • • • • • • • • • Update the statement of purpose for the home. Ensure all care plans are dated and signed by the person developing the plan. Ensure all risks are identified, and a risk assessment undertaken with an action plan how the risk is to be minimised. Develop activity plans for service users’. Contact the community dietician and ask advice regarding menus and menu planning. Provide training in safeguarding adults for all staff that have not had the training. Replace all carpets where identified in the main body of the report, and decorate areas where required. Provide dispensed soap and paper towels in all areas where personal care is delivered, including service users rooms. Replace all failed double glazed window units and provide grab rails in the fist floor WC. Continue to ensure NVQ training is takes place. Develop a quality monitoring system. 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. DS0000001491.V300839.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 DS0000001491.V300839.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in these outcomes is adequate. This judgement has been made through using available evidence including a site visit to this service. The statement of purpose needs updating. The admissions and pre admissions process is adequate. The scale of charges is still unclear. EVIDENCE: The homes Statement of Purpose and function was inspected. It needs updating to include the current managers name. It also talks about “sleep in staff”. As this is no longer provided, reference to it should be removed. The admission process was looked at for the one service user admitted since the last inspection. Because of limitation in his communication skills it was not possible to confirm with him, whether he had had a trial visit or not, or whether he had been assessed as being suitable to be admitted to the home. However, he told the inspector that he liked the staff and the food, and going home at weekends. Judging from how happy he appeared to be, and the way he behaved with the staff, there was no indication to believe otherwise. The proposed manager said pre admission assessments would be made for any future admissions. The scale of charges information however, is still unclear; as it does not clearly identify the full amount each service user pays for their care. DS0000001491.V300839.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is poor. This judgement has been made using available documentary evidence during a site visit to the home. The standard and quality of planned care needs to be improved to ensure that all clients can be sure that their health, personal care and leisure time needs will be fully met. Risk assessments need to be completed where there is an identified risk. EVIDENCE: Two sets of care documentation were reviewed. All contained a pen picture of the client, a health history and life history. There was evidence in these documents that they had been recently reviewed, however, both care plans reviewed were neither dated nor signed, there was no evidence that certain risk assessments, such as tissue viability, nutrition, continence and manual handling had been undertaken. The risk assessments of certain clients were not completed fully with the action taken to minimise the assessed risk. Activity plans were not completed in both plans assessed, which gives the impression that there had been no activities provided for the two service users’. However there was evidence that recreation and activities do take place. DS0000001491.V300839.R01.S.doc Version 5.2 Page 10 The care staff on the premises at the beginning of the inspection told me that none of the service users’ had the ability to judge for themselves any risks they should take. One male staff member said, “ We are aware of their limitations. You just have to provide adequate supervision, as they have no ability to judge danger for themselves, you just have to watch them very carefully, and move them away from anything that would harm, or hurt them”. He said “ we know our residents very well, and can almost second guess what they will or will not do”. Sexual health care of the service users’ was discussed with the manager, who said every effort is made by the staff team to address issues as they arise. DS0000001491.V300839.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in these outcomes is adequate. This judgement has been made using available evidence and a site visit to the home. The range of activities provided varies according to the wishes of the clients, many of whom go on planned outings, shopping with staff and annual holidays. Menus are planned, however, not in conjunction with the community learning disabilities dietician. EVIDENCE: Although service user plans did not identify in detail any leisure time pursuits provided for them, staff spoken to said all four of them attend various day care centres between two and four times each week. They also said one of the service users had a static caravan at Reighton Sands, and that two of the service users were using the caravan and going for a holiday, on the 26th September for one week. One of the service users is also going on holiday for a week to Spain. Two service users are taken out to help with the weekly shopping. Menus were inspected, and appeared to be varied and nutritious in value, however, when questioned, the staff said there was no liaison with the DS0000001491.V300839.R01.S.doc Version 5.2 Page 12 community dietician to ensure the content of the food provided meets the dietary needs of this client group. The acting manager also said none of the service users were capable of handling their own finances, and that none were capable of being involved in staff interviews. The kitchen area is a combined kitchen/dining room with a door leading directly into the garden. Menus appeared to be nutritious in value, and were four weekly and rotational with the main meal of the day being teatime. Many of the service users’ choose to stay in the kitchen the majority of the time, accompanied by members of staff. They are not however involved in the preparation of meals. Although there is an insectocutor fitted in the kitchen, there are no fly screens fitted either to the window, or to the door that leads out directly to the garden area. Concern was expressed to the manager regarding this, as presently flying insects could contaminate any food being prepared. The manager was advised to contact the Environmental Health Department in the area the home is located and seek their advice regarding this. DS0000001491.V300839.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19 Quality in this outcome area is good. This judgement has been made using available evidence and a site visit to the home. Service users receive support from specialist healthcare professionals. EVIDENCE: There is a mix of male and female staff employed at the home. I spoke to the one service user who had communication skills about his care, and asked him if he was happy with the way he was being cared for. He said, pointing to the two carers in the room, “I like them a lot”. There was evidence in the Pre Inspection Questionnaire that service users are registered with a local GP, and that if they need nursing care this is provided by the district nurses attached to the GP surgery. Other professionals help, such as speech therapy, community psychiatric nurse intervention, physiotherapy, speech therapy, dental and podiatry, and Community Psychiatric advice are accessed via the service users’ GP. End of life situations were discussed with both the staff and the manager, who said they would be dealt with in a sensitive way. The staff said they had not had any training in death and dying, but the manager said he had already DS0000001491.V300839.R01.S.doc Version 5.2 Page 14 identified training was needed in this area, and intended to do some training on bereavement. The medication system was reviewed in light of the previous inspection report stating out of date medications were stored. The home uses a monitored dosage system of medication control. Each service user receives their own medication via individual blister type packs, prepared and hermetically sealed by the dispensing chemist. All prescription sheets are collected from the GP surgeries, and the disclaimer signed by a member of staff prior to being taken to the chemist. MAR (medication administration record sheets) were appropriately completed. There was no stored out of date medication. All care staff with the exception of the newest recruited member of staff have been provided with training (Via Distance Learning by Joseph Priestley College) on safe handling of medication. All the current service uses’ need maximum help with medication, and get it. The medication system is safe. DS0000001491.V300839.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence and a site visit to the home. The manager should ensure that up to date training in adult abuse awareness is provided for all staff due an update, and that the Adult Protection policy/procedure is available at all times. EVIDENCE: There have been no complaints either in house or directly to the Commission since the last inspection. When staff were asked what training they had been provided with regarding to safeguarding adults, they said they had briefly covered it in their foundation training. They were however clear on the action they should take if abuse was suspected, and demonstrated awareness and knowledge of POVA. The manager also said advocacy services were used, and that he and a taxi driver who regularly visits the home are advocates for two of the service users. The Adult Protection policy/procedure was not able to be located on the day of the visit. There is also no policy on Physical Intervention/restraint. The manager said all staff had received training on CPI (breakaway techniques) DS0000001491.V300839.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30. Quality in these outcomes is adequate. This judgement has been made using available evidence and a site visit to the home. Many of the areas in the home need attention to décor. Carpets which have been cleaned, and which were identified in the last inspection as in need of cleaning/replacing must now be replaced. However the manager said decorating the home was his priority and arrangements have been made to replace the lounge, hall and staircase carpets. All double-glazed sealed units identified to the manager, as having failed should be replaced. Dispensed soap and paper towels must be provided in all areas where personal care is delivered. The cause of the damp patch in the bathroom should be identified. All fire exits must be kept free from clutter. EVIDENCE: One bedroom on the top floor is showing signs of wear and tear and needs redecorating. The wardrobe is broken in this area. There are no paper towels for staff use in any of the bedrooms in the home. DS0000001491.V300839.R01.S.doc Version 5.2 Page 17 Attention is needed to the paintwork in one room. The radiator guard is also broken in this area. The downstairs WC was void of paper towels, and there were no grab rails around the WC There is also no dispensed soap and paper towels in the main bathroom. (Dispensed soap and paper towels must be provided in all areas where personal care is provided so that control of infection is not compromised.) The cause of the damp patch in the bathroom, identified to the manager at the time of the visit, must be identified and rectified. The main downstairs lounge is very dark and dingy, and not at all inviting for service users’ to sit in and relax. Some of the double glazed window units in the conservatory need attention, as the windows appear very misty. There is also an organ in this area, which is to be relocated due to it currently blocking the fire exit. The double glazed units have also failed in one of the service users’ bedrooms. This was identified to the manager during the tour of the premises. The dining area in the home is very rarely used. The proposed manager said it is only used once a year at Christmas. Consideration should be given to utilising this area, as it could be used for a variety of reasons, one being an activities room. Many of the carpets, which the proposed manager said had been cleaned, are still in a poor condition and need replacing. DS0000001491.V300839.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32 and 36 Quality in these outcomes is poor. This judgement has been made using available evidence and a site visit to the home. Formal supervision is not currently systematically being addressed. Staff rotas do not show evidence of hours worked by staff, or staff roles. Service users could be placed at risk during the night; there only being one waking member of night staff. EVIDENCE: Recruitment files of two staff were inspected. One staff member has been employed as a support worker for 23 days, and one staff member for 11 months. One staff member said she was receiving formal supervision, whilst the second staff member had not received any formal supervision since April 06. The files contained evidence of a robust recruitment procedure, and one contained evidence that Induction and Foundation training has been implemented. Both members of staff have been enrolled on various training courses including manual handling, principles of care, basic food hygiene and first aid since commencement of employment; one of them having attended most of them. Both sets of recruitment documentation were complete with photo identification. DS0000001491.V300839.R01.S.doc Version 5.2 Page 19 Inspection of one set of documentation identified the staff member was working on a holidaymakers visa until October 06 when it expires. The management must take steps to ensure this is followed up and that the staff members’ legal status to remain in the country is verified. Staff rotas were questionable as they did not contain staff roles, or hours the staff had worked. Information documented regarding shifts worked were E and L. When asked about this the proposed manager said all rotas were now computer generated to identify roles of staff and hours worked. He also said any agency staff employed to work at the home had worked at the home before and were familiar with the home and the service users’. Concern was expressed at there only being one member of waking night staff on duty since November 2005, when extra hours to provide 1–1 care for one service user were removed. The manager said there was always a senior member of staff on call in case of an emergency. Three out of the seven care staff have achieved NVQ at level two, and the remainder of the care staff have been booked on courses at Park Lane College to undertake this training. DS0000001491.V300839.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 42 and 43 Quality in these outcomes is adequate. This judgement has been made using available evidence and a site visit to the home. The home appears to be fairly well run, and the service users’ cared for by a team of staff who appear motivated, and committed to their service users well being The manager who has only been in post since 14 August 06, needs to apply for registration. He also needs to successfully complete his NVQ level 4 by the end of 2007. The manager said there is currently no quality assurance and quality monitoring systems in place other than the monthly provider Reg 26 visits. This should be developed and implemented. The home has no emergency call system fitted, therefore staff, particularly on night duty, have no way of summoning help when needed, except for shouting for help. Whilst shouting for help during the day receives an adequate response from fellow workers. The management must seek ways of improving staffing during the night time period, and either fit an emergency call system, provide evidence that service users are not placed at risk, and provide evidence why an emergency call system is not required. DS0000001491.V300839.R01.S.doc Version 5.2 Page 21 EVIDENCE: The proposed manager is acquiring the skills and knowledge to provide effective leadership. Staff appear to be well motivated. The interests of the clients are seen as very important to the manager and staff. The current proposed manager who has worked at the home for four years, has been acting manager since 14 August 06. There has still been no application for registration of the current proposed manager received by the commission. The current proposed manager who has worked at the home for four years, has been acting manager since 14 August 06. He appears to be very enthusiastic, and said he intends to look at the care plan documentation, and adapt it for the one service user who can make a contribution to his care. There have been no relative comments cards received from the home, and the manager said he doesn’t remember them arriving at the home. There has however been comments cards received from two of the GP’s who provide the service user’ medical care. He said he has support from the current area manager who carries out the Regulation 26 visits, and said” she is like a breath of fresh air”. She speaks to the service users’ who are able to communicate, and speaks to the staff. Asks them how the atmosphere of the home is and if there are any problems, and if they are receiving formal supervision. Apart from the monthly provider visits, there is no other quality assurance system in place in the home. Health and Safety documentation was reviewed and found to be in order with the exception of the servicing of the hoist and Parker Bath, which are due for a service September 06. DS0000001491.V300839.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 5 3 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 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 2 3 1 3 x 1 3 DS0000001491.V300839.R01.S.doc Version 5.2 Page 23 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 YA1 Regulation 4 Requirement The registered person shall ensure the Statement of Purpose and Function of the home is amended to include the current managers name, and any qualifications and experience. An updated copy must be forwarded to the Commission. The registered person shall ensure all service user plans are dated when written, and signed by the person prescribing the care. The registered person shall ensure that all relevant risk assessment such as tissue viability, nutrition, and manual handling are completed fully, and include an action plan to determine how the risks should be minimised. The registered person shall: a) ensure all the carpets are either cleaned or replaced in the hall, corridor and stairs. (previous timescale of 1.11.05 and 01/04/06 not met.) b) Replace all failed double glazed window units. DS0000001491.V300839.R01.S.doc Timescale for action 30/10/06 2. YA6 15 27/11/06 3. YA9 13 (4)(c) 27/11/06 4. YA24 23 25/12/06 Version 5.2 Page 24 5. YA17 16(2)(i) 6. 7. YA23 YA29 13(6) 16(2)(c) 23(2)(n) 16(2)(j) 8. YA30 9. YA39 24(1)(a and b) 10. YA39 9 11. YA42 12(1)(a) 12 YA33 18(1)(b) The registered person shall consult with the community dietician regarding food provided for the service users, to make sure they are receiving a nutritional wholesome diet. The registered person shall ensure all staff receive training on abuse awareness. The registered person shall ensure that grab rails are provided in the WC on the first floor level. The registered person shall ensure dispensed soap and paper towels are provided in all areas where personal care is delivered, including service users’ bedrooms. The registered person shall establish and maintain a quality monitoring system for the quality of care provided at the home, based on seeking the views of the service users’. . The registered person shall ensure the manager has a relevant management qualification. The registered person shall, in the interest of health and safety of service users’, either install an electronically operated emergency call system, or provide adequate reasons why this is not required. The registered person shall, having regard to the size of the care home, the statement of purpose and the needs of the service users’, ensure that at all times suitably qualified, competen5t and experienced persons are working at the home, in such numbers as are appropriate for the health and DS0000001491.V300839.R01.S.doc 27/11/06 26/02/07 27/11/06 27/11/06 22/01/07 17/12/07 22/01/07 30/11/06 Version 5.2 Page 25 welfare of service users’. Particularly on night duty. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA32 Good Practice Recommendations The organisation must ensure that 50 of care staff have an NVQ qualification by 2007. ( 31.12.05 timescale agreed from a the previous inspection). Develop an activity care plan for each service user, that clearly identifies activities they would like to take part in. Contact the environmental heath department in the area the home is located and ask advice regarding the fitting of fly screens to the kitchen window, and door. 2 3 YA14 YA30 DS0000001491.V300839.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000001491.V300839.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. 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