Inspection on 18/11/05 for Radcliffe House

This inspection was carried out on 18th November 2005.

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

Other inspections for this house

Radcliffe House 15/10/07

Radcliffe House 23/06/06

Radcliffe House 28/04/05

Radcliffe House 06/04/04

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

CARE HOME ADULTS 18-65 Radcliffe House 11 Radcliffe Road East Croydon Surrey CR0 5QG Lead Inspector Peter Stanley Unannounced Inspection 18th November 2005 9:30 Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 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 Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 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. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Radcliffe House Address 11 Radcliffe Road East Croydon Surrey CR0 5QG 020 8680 4586 020 8680 4586 NO EMAIL 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) Quality Care Choice Limited Mr Alfred Nee Otokunor Okine Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23) of places Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th April 2005 Brief Description of the Service: Radcliffe House is set in a large well-maintained garden and has nineteen single and two double bedrooms, in addition to a communal lounge, smoking and dining room. The home is conveniently sited for local transport (buses and trams) and within walking distance of the centre of Croydon. The nearest mainline station is East Croydon with easy access to London and the South Coast. The home provides care for 23 service users with long term mental health needs. Some residents have a history of additional problems concerning substance abuse. If these continue once they are admitted to the home they would be asked to leave. The aim of the home is to rehabilitate service users so that they can move on to live independently or on a more independent living scheme. The home aims to rehabilitate service users within a two-year period at which point the home will reassess the appropriateness of the placement. Historically the home has had problems moving service users on to more appropriate placements where it is clear that rehabilitation is not appropriate for particular users. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over half a day and involved discussion with the registered manager, members of staff on duty and service users. The inspector spoke at length with three service users and more briefly, with two others. Records and staff rotas were examined together with documentation relating to the admission of a recently admitted service user. The home was evidenced to provide a generally good standard of care, with service users providing very positive feedback regarding the home and support provided by staff. Staff members spoken to demonstrated an awareness and knowledge of service users’ needs and indicated that they feel well supported in terms of their training and practice. There are six requirements, one of which (Quality assurance) is outstanding from the previous inspection. Three recommendations are also made. All of the requirements were discussed and agreed at the time of the inspection with the registered manager. What the service does well: Prospective service users are provided with all the information they require, and are provided with the opportunity to visit, and stay overnight if they wish, before deciding whether the home is likely to meet their needs. The home is able to demonstrate that the range of needs presented by service users are being properly assessed, and appropriately met. Service users’ health, personal and social care needs are set out in an individual plan of care, and are being appropriately reviewed. Service users have their health, personal and social care needs set out in an individual plan of care, and are fully involved in the care planning process. Reviews are taking place on a regular basis. Service users are thoroughly assessed regarding potential risks to their health and safety, and are enabled to take responsible risks wherever possible. Service users can be assured that information about them is being handled appropriately and confidentiality respected. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 6 Service users have varied opportunities for engaging in appropriate leisure activities. Service users are being safeguarded by the home’s policies and procedures for the receipt, recording, storage, handling, administration and disposal of medicines. Service users have access to safe and comfortable communal facilities. Staff have clearly defined roles and responsibilities, and are sufficient in numbers to meet service users’ needs. Staff are being appropriately supported, supervised and appraised. Generally, service users’ rights and best interests are being safeguarded by the home’s record keeping, policies and procedures. A checklist would, however, assist in tracking when reviews of these are due. What has improved since the last inspection? What they could do better: While service users’ wishes regarding their ageing, illness and death are being handled with respect, training is required to assist staff to develop relevant skills and provide positive support to service users when bereavement or loss occurs. The home’s policies, procedures and practice indicate that, generally, service users are being protected from abuse and are living in a safe environment. However, for service users to be sufficiently safeguarded, those staff who have yet to complete statutory adult protection training, must do so. While, generally, service users are found to be living in a homely, comfortable and safe environment, the home must ensure that adequate heating is being provided at all times. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 7 While some aids and adaptations have been provided, service users’ capacity to function independently would be maximised by an occupational therapist assessment of the home. The home needs to demonstrate, through the development of its quality assurance processes, that it is obtaining widespread feedback regarding the extent to which the home is meeting its aims and objectives. The inspector was generally satisfied that the health, safety and welfare of service users and staff are being appropriately promoted and protected. The home does, however, require an up-to-date health and safety inspection. 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. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 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 Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Prospective service users are provided with all the information they require, and the opportunity to visit, and stay overnight if they wish, before deciding whether the home is likely to meet their needs. The home is able to demonstrate that the range of needs presented by service users are being properly assessed, and appropriately met. Service users’ health, personal and social care needs are set out in an individual plan of care, and are being appropriately reviewed. Each service user is provided with a service user agreement. This is now written in a format which is appropriate to service users living at the home. EVIDENCE: Standards 1, 2, 3, 4 and 5 assessed. Standards 2 and 3 assessed as met at the last inspection. The home has compiled a statement of purpose outlining the aims and objectives of the home, and the facilities and services it provides. The Statement of Purpose includes all the information detailed in Schedule 1 of the Care Homes Regulations (2001). The home has developed an excellent service user’s guide, which is written in a format/language suitable for the service users and contains all the elements of regulation 5(1)(2)(3). The inspector was Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 10 advised that these documents are reviewed 12 monthly, and evidenced that they have been reviewed and updated in 2005. The home has admitted one service user since the last inspection. The inspector examined the service user’s file and found all necessary assessments, risk assessments and care plans to be in place, together with details of reviews held. The inspector met the service user who following his admission has settled in well. He indicated that he likes the home and that the support being provided is meeting his needs. The registered manager advised that any admission is carefully planned, and that following referral he first visits the potential service user to complete assessments. The service user is then encouraged to visit the home, with short visits being followed by overnight and weekend stays, if appropriate. Placements are reviewed on a day-to-day basis and are not confirmed as permanent placements until a CPA meeting takes place after three months of placement. The home only admits emergency or short-term placements if the service user meets the homes admission criteria. The home has a service user agreement in place; following an earlier requirement, this has been amended so as to refer to a three-month ‘trial period’, and the registration authority has been amended to the CSCI. Following a requirement from the previous inspection, this has been revised so that the agreement is written in a more appropriate format for service users living at the home. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 11 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): Service users have their health, personal and social care needs set out in an individual plan of care, and are fully involved in the care planning process. Reviews are taking place on a regular basis. Service users are thoroughly assessed regarding potential risks to their health and safety, and are enabled to take responsible risks wherever possible. Service users can be assured that information about them is being handled appropriately and confidentiality respected. EVIDENCE: Standards 6, 9 and 10 assessed. Standards 6 to 9 met at the last inspection. The home has a comprehensive and thorough approach to care planning, with care plans being based on the Care Planning Approach. Standards 6 and 9 were assessed as met at the last inspection, since when there has been one new admission to the home. Based on the initial assessments received from the referring agency and the home’s own assessments and risk assessment, a service user plan has been put in place. This provides detailed information evidencing how service users’ needs are being addressed, and the involvement of the service user in contributing to their care plan. Risk taking plans (based Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 12 on risk assessments) have been drawn up, with any restrictions being clearly identified and agreed by the service user. The service user plan has been reviewed and updated, and a review (involving the care coordinator) held on 29/9/05. The home has guidance on the Data Protection Act and a confidentiality policy in respect of personal information held in relation to service users. The policy states that service users have the right to access personal information held about them by the home. The home has included the confidentiality policy into the homes statement of purpose thus ensuring that service users and their families have access to it. Service user and staff files are held securely within a lockable office. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 13 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): Service users have varied opportunities for engaging in appropriate leisure activities. EVIDENCE: Standard 14 assessed. These standards were fully covered at the last inspection, all standards having been met. Since the last inspection the home has had a garden party for service users and staff to which neighbours, friends and relatives were invited. Entertainment and refreshments were provided. The inspector saw photographs of the event on one of the home’s notice-boards. There have also been day trips organised for the home’s service users to Bournemouth and Bognor Regis, both of which proved to be successful. The inspector spoke to a number of service users who indicated that there is a varied range of activities available which meet their needs; there was a drawing session in progress on the day of inspection. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users are being safeguarded by the home’s policies and procedures for the receipt, recording, storage, handling, administration and disposal of medicines. While service users’ wishes regarding their ageing, illness and death are being handled with respect, training is required to assist staff to develop relevant skills, and provide positive support to service users when bereavement or loss occurs. EVIDENCE: Standards 20 and 21 assessed. Standards 18 to 20 met at the last inspection. The home has appropriate medication policy and procedures in place. All staff have received accredited medication training, and there has been some recent additional training provided by the visiting pharmacist, who also completes an audit every three months. Medication charts for a number of service users were examined and found to be in order. Other records relating to receipts and returns of medication were also found to be satisfactorily maintained. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 15 Since the last inspection the home has experienced the loss of a service user who was unexpectedly taken ill and subsequently died in hospital. The inspector was satisfied that this had been dealt with appropriately by the home, and that the service user’s family had been kept fully informed by the home and their wishes respected. The inspector was informed that the service user had been resident in the home for a number of years and that his passing has deeply affected other residents and staff. The inspector discussed the need for training in bereavement and loss to assist staff in coming to terms with their own feelings, and to develop relevant insights and skills with which to support service users throughout their loss. The wishes of service users regarding the eventuality of terminal illness or death are recorded on service user files. The notes indicate that service users have been consulted about their wishes and that religious and cultural aspects are recorded. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home’s policies, procedures and practice indicate that, generally, service users are being protected from abuse and are living in a safe environment. However, for service users to be sufficiently safeguarded, those staff who have yet to complete statutory adult protection training, must do so. EVIDENCE: Standard 23 assessed. Standard 22 met at the last inspection. The home has an Adult Protection procedure, which is in line with Croydon Local Authorities procedures. The manager has attended an Adult Protection course facilitated by Croydon social services. All but two staff have now attended this training; a requirement applies for the remaining staff to do so. The manager has not yet been able to undertake the three day adult protection ‘training for trainers’ course. It is recommended that the manager complete this training as this can then be cascaded to other staff. Since the last inspection all staff have attended a half-day POVA (Protection of Vulnerable Adults) training course. This was held at the home and was facilitated by an accredited trainer. No allegations of abuse have been recorded since the last inspection. When complaints relating to service users’ mental health needs are made these are recorded in the service users care notes and discussed with the C.P.N. The home has a safe that is fixed to the floor for the safekeeping of service user’s money and valuables. All staff have undertaken accredited physical intervention training in accordance with Department of Health guidelines. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 17 Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): While, generally, service users are found to be living in a homely, comfortable and safe environment, the home must ensure that adequate heating is being provided at all times. Service users have access to safe and comfortable communal facilities. While some aids and adaptations have been provided, service users’ capacity to function independently would be maximised by an occupational therapist assessment of the home. EVIDENCE: Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 19 Standards 24, 28 and 29 assessed. Standards 24 to 27, and 30, were met at the last inspection. Generally the home provides a homely, safe and comfortable environment. The inspector noticed on the day of inspection, however, that there was an insufficient level of heating in the communal areas, and understands that the heating is not kept on constantly throughout the day. Given that this was a cold winter’s day, this is placing the health of service users at risk and is not acceptable; this was pointed out to the manager, and a requirement is made for the home to be kept properly heated throughout the day and night. Radcliffe House has several communal spaces for service users, and the house has a very homely feel. There is room for all the home’s service users to sit together, or to receive visitors in private, in either of the home’s two lounges or in the dining room. The inspector spoke to a number of service users who expressed their satisfaction with the communal facilities provided. The home has a large well-maintained garden with a patio area and lawn. In addition, the kitchen area is clean and domestic in scale, and service users are encouraged to make use of the facilities if they wish. The home does not accommodate people with significant physical disabilities and is not suitable for people who are wheelchair dependent. There are, however, a number of older service users who have some physical impairment. One service user, who uses a walking frame, has a downstairs bedroom with its own shower facility. There is a call bell system in the bathroom. The inspector noted that while there has been an individual-based assessment for this service user, the home itself has not been assessed by an Occupational Therapist for any adaptations or aids that would assist in meeting the collective needs of service users. The inspector discussed this with the registered manager and it was agreed that referral for an assessment would be referred to the occupational therapist who is based in the area community mental health team. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Staff have clearly defined roles and responsibilities, and are sufficient in numbers to meet service users’ needs. Staff are being appropriately supported, supervised and appraised. The supervision format has been redesigned so as to provide more space for recording the issues discussed in supervision and the actions/decisions agreed. EVIDENCE: Standards 31 and 36 assessed. Standards 32 to 36 were met at the last inspection. All staff are provided with detailed job descriptions, and are issued with the GSCC (General Social Care Council) Code of Conduct. The inspector spoke to three staff members during the inspection. This comprised of a shift team leader and two support staff. They presented as well informed and aware of service users’ needs, and demonstrated a caring and professional approach to their duties in supporting service users. A key worker system is in place. Service users who spoke to the inspector expressed very positive feelings regarding staff and the support provided, and the interactions between staff and service users were observed to be empathic and purposeful. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 21 Supervision sessions are being held on a monthly basis and are facilitated by the manager and by one of the two shift leaders, who is responsible for the supervision of some staff. Following a recommendation from the last inspection the supervision format has been redesigned so as to provide more space for recording the issues discussed in supervision and the actions/decisions agreed. An agenda would, however, assist in identifying those issues, which the supervisor and supervisee wish to discuss in supervision. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Feedback from service users indicates that their views are generally being listened to and taken into account in the decision-making processes within the home. The home needs, however, to demonstrate, through the development of its quality assurance processes, that it is obtaining widespread feedback regarding the extent to which the home is meeting its aims and objectives. Generally, service users’ rights and best interests are being safeguarded by the home’s record keeping, policies and procedures. A checklist would, however, assist in tracking when reviews of these are due. The inspector was generally satisfied that the health, safety and welfare of service users and staff are being appropriately promoted and protected. The home does, however, require an up-to-date health and safety inspection. EVIDENCE: Standards 39, 40, and 42 assessed. Standards 37, 38 and 41 were met at the last inspection. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 23 A requirement from the last inspection for a Quality Assurance audit to be put in place has been partially met. Feedback from a survey with service users has been obtained and presented in a report, but this process of consultation needs to be extended so as to include surveys with the relatives, friends and advocates of service users, and with relevant professionals such as care managers and community psychiatric nurses. Feedback regarding the home’s performance, from other sources such as visitors’ comments or concerns, and from discussions at staff and service user forums, should also be included. The inspector examined a range of policies and procedures contained within a manual; these were found to be appropriately maintained, and were signed and dated. While it was evidenced that the home is reviewing and updating these on an annual basis, a checklist would assist in tracking when reviews are due. The inspector recommends that a policies and procedures checklist is maintained at the front of the policies and procedures manual, providing the date when each entry was last reviewed. Two health and safety requirements were made at the previous inspection. These related to the need for the home to receive an up-to-date fire safety inspection and for up-to-date accredited fire prevention training to take place. Both of these have been met, on 20/9/05 and on 25/8/05 respectively. The inspector identified at the last inspection that the home last received a health and safety inspection on 27/3/03. This needs to be updated; a requirement applies. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X 3 3 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X 3 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 X X X X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Radcliffe House Score X X 3 2 Standard No 37 38 39 40 41 42 43 Score X X 2 3 X 2 x DS0000025828.V264310.R01.S.doc Version 5.0 Page 25 YES Are there any outstanding requirements from the last inspection? Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 26 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 YA21 Regulation 18(1)a) & (c) Requirement The registered person must ensure that all staff are provided with training in bereavement and loss. Timescale for action 31/03/06 2. YA23 13(6) 3. YA29 23(2)(n) The registered person must 31/03/06 ensure that those staff who have not yet attended Croydon’s statutory adult protection training, do so within the prescribed time-scale. The registered person must 31/03/06 arrange for the home to be assessed by an Occupational Therapist for any aids or adaptations that would assist in meeting the needs of service users within the home. 4. YA39 5. YA42 6. YA24 Radcliffe House 24(1)a) The registered person must 01/03/06 &(b),(2&(3 ensure that a Quality Assurance audit is put in place, evidencing that information gathered from surveys, meetings and other types of feedback has been collated. This should be published and made available to service users, their relatives and representatives, the CSCI and other interested parties. 13(4)(a) & The registered person must 31/03/06 (c) ensure that the home receives an up-to-date health and safety inspection. 18/11/05 23(2)(p) The registered person must ensure that all areas of the home which are used by service users are kept properly heated DS0000025828.V264310.R01.S.doc Version 5.0 Page 27 throughout the day and night. 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 YA23 YA40 Good Practice Recommendations The inspector recommends that the registered manager undertakes the Croydon 3 day adult protection training for trainers course in adult protection. The inspector recommends that a policies and procedures checklist is maintained at the front of the policies and procedures manual, providing the date when each entry was last reviewed. Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Radcliffe House DS0000025828.V264310.R01.S.doc Version 5.0 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!