Inspection on 07/02/06 for 38 Redgate Court

This inspection was carried out on 7th February 2006.

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

Other inspections for this house

38 Redgate Court 10/10/07

38 Redgate Court 28/11/06

38 Redgate Court 10/05/06

38 Redgate Court 14/09/05

38 Redgate Court 14/02/05

38 Redgate Court 06/09/04

38 Redgate Court 19/03/04

Similar services:

Coopers Mill Ltd

Pocklington House

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

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

CARE HOME ADULTS 18-65 Redgate Court (38) Peterborough PE1 4XZ Lead Inspector Lesley Richardson Unannounced Inspection 7 February 2006 2:30 th Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 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 Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 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. Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Redgate Court (38) Address Peterborough PE1 4XZ 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) 01733 313501 01733 313501 www.sense.org.uk Sense East Elizabeth Ann Gray Care Home 6 Category(ies) of Learning disability (6), Sensory impairment (6) registration, with number of places Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. LD only in association with SI Date of last inspection 14th September 2005 Brief Description of the Service: 38 Redgate Court consists of a purpose built property, situated on a residential estate on the northeastern edge of Peterborough. The home is a two-storey, semi-detached property in an accommodation complex catering for adults with learning disability. It is owned by Sense East and provides care and support for up to 6 people with learning disability, associated with sensory impairment. The home has 6 individual bedrooms; 5 on the upper floor and 1 on the ground floor. There is a bathroom with shower and toilet on both floors, an open planned lounge dining area and a kitchen. There is a conservatory leading to the large, well maintained garden, which is shared with the adjoining house. The home is within walking distance of local shops, pubs, a post-office and public transport. Peterborough city centre is about 5 miles away and is easily accessed by public transport. Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 6 hours and was carried out as an unannounced inspection on 7th February 2006 and 27th February 2006. It was the second inspection of this home for the 2005-2006 year. The lead inspector and a second inspector attended the second part of the inspection on 27th February. Five and a half hours were spent examining records and documents and one and a half hours were spent with staff members and undertaking a tour of the home. Not all the people who live at the home were present during the inspection. Due to the levels of combined learning disability and sensory impairment in the people who live there, conversations with two people were brief and consisted of mainly greetings and an explanation of the inspectors visit. The manager was present for part of the first inspection visit. The remaining visits were conducted with the deputy manager and a team leader. This inspection has resulted in many requirements being made to improve the service. What the service does well: What has improved since the last inspection? What they could do better: There are a number of areas the home must improve to make sure they meet all the standards and regulations, and bring them up to an acceptable standard. Care records that are written to advise staff members about the best way to care for the people who live at the home are difficult to read and do not provide all the information needed. This makes it difficult for staff, especially new or agency staff, to find out exactly what to do in any situation and puts the people who live at the home at risk of not receiving the correct care. Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 6 Staff members must receive training to make sure they have the knowledge and skills to care for all aspects of residents’ needs. Two areas where this must be improved are medication and specific needs, such as diabetes. There must also be better referrals to health care professionals to make sure care given is appropriate and the person involved remains healthy. The environment of the home needs improvement. There is no programme of maintenance, which means there are a number of areas that need to be repaired or replaced. Noticed in this inspection is plasterwork and paint that is cracked and peeling, absent lights and light shades, tiling in bathrooms and showers that is stained or missing, and a loose toilet seat. It is recommended that the home start a programme to identify areas in need of maintenance and records when areas or equipment becomes defective. An immediate requirement notice was issued for 6 areas that were considered needed urgent attention; a response has been received from the provider to show how 5 of these have been met. Records must be kept to show the home is completing health and safety checks, such as hot food temperatures, records of meals eaten and fire alarm tests. Not all records are being completed with enough detail or at all for periods of several months. This must improve to ensure the health and safety of service users. Reporting of issues around adult protection also has to follow local authority guidance to make sure service users are not at risk of abuse. Records of the money holds on behalf of the people who live there must be accurate and must detail why changes have been made. This is to make sure vulnerable people are not financially abused. People who live at the home and their relatives or representatives have little opportunity to comment formally about how the home is run. There has been no survey report identifying how the home could improve since 2003. This needs to change so that people living at the home have a say and a choice in how they would like to live. 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 Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 7 contacting your local CSCI office. Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 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 Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 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): EVIDENCE: These standards were not assessed on this occasion. Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 There is no clear or consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. EVIDENCE: The home has three files that provide information about how to care for service users. One file that contains mostly older reports and archived material, a folder that contains up to date information and is taken with the service user when they attend day services, and a medical/medication file that contains details of health related issues and medication records. The care records for four service users were looked at. The documentation for one service user was looked at as a result of an anonymous complaint. Care plans are written to advise staff members of how to meet service users physical needs and identify aims. These are supplemented by reports from the Challenging Behavioural Specialist and person centred plans completed by the home. However, one service user’s file and folder did not contain a care plan that would enable new or agency care staff to fully meet this person’s needs, although guidelines were available for some specific needs. Information in two Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 11 service users folders, which contains the most up to date information, had not been updated since 2004. Although one of these service user’s A4 files contained a review of the service user’s profile in February 2005, a memo regarding strategies for improving the service user’s mobility, dated February 2006 was seen pinned on the notice board in the main corridor. The care plan of another service user was reviewed in January 2006, but had not been changed to advise staff members of how best to manage the service user’s challenging behaviour. Neither did this care plan give clear guidance about how to reduce risks or pre-empt behaviour. Two areas in the care plan, ability to make decisions and maintaining a varied life, finish mid sentence and do not give clear guidance about why boundaries have been set or what the service user must not have access to. Information from the Challenging Behaviour Specialist was available for this service user, but was dated October 2004. Further information and advice from recent meetings was kept in a memo folder for staff members to read, or in a filing cabinet to which staff members do not have access. Guidance about how repeated requests from one service user should be managed cause concern due to the definitive and disenabling terminology used. For example staff are instructed to tell the service user, ‘No you are not having them ever’ and, ‘… is never going home …’. While it is acknowledged the information given to service users may have to be clear and concise, the inspectors felt these comments may be seen as punishing. Because of the number of different places care records are kept in the home it would be very difficult for new or agency staff members to obtain a clear understanding of each service user’s needs and how these should be met. Care records are poorly dated, giving little guidance about whether a particular document is current or out of date. Not all documents are signed by the person writing the entry, which makes clarifying information difficult and can potentially result in incorrect care being given. It is difficult to identify how service users are supported to take risks. One service user has information about attending a gym club but advises staff of the need to complete a risk assessment beforehand. There was no evidence a risk assessment had been completed. Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 Records of meals provided to service users are not detailed enough to ensure nutritional needs are being met. EVIDENCE: Service users accompany staff members on shopping trips and they help with food preparation. Snacks are available throughout the day and service users, who are able to, can make drinks when they wish. Fresh fruit and vegetables are offered and meals are prepared on a daily basis. The home keeps a record of meals taken by service users and a general 4-week rotating menu. Although the deputy manager said service users are not dependent on a strict menu regime and therefore meals can be changed to accommodate themes, such as a week where meals and activities (clothing, flags, information) centre on different countries. Records detailing food that service users are given must be properly documented to ensure dietary needs are met. Sandwich fillings must be included, and if service users only have sandwiches for lunch there must also be information about what was eaten at other meals. There were four days Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 13 when this occurred, which indicates that service users ate little more than bread for the entire day. Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 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): 19 and 20 The systems for the administration of medication must improve to ensure service users are not at risk. EVIDENCE: Service users have access to healthcare professionals, such as a Challenging Behaviour Specialist, on a regular basis and as required. Staff said one service user who is diabetic has had contact with a specialist in the field, but was unable to identify when this contact was or the role of the specialist. There was no record in the medical/medication file to show the outcome of this meeting. The medication administration records (MAR) for one service user showed incomplete instructions regarding the dosage of the medication. There was nothing recorded on the MAR sheet that indicated the dosage of the medication given, or that this was recorded elsewhere. Instructions for the medication dosage were available on a separate piece of paper in the file. Medication prescription must be clearly given on the MAR sheet to reduce the risk of medication errors and ensure service users are safe. The team leader said training is given to staff on an annual basis for the administration of rectal diazepam, but that medication training is given during induction and senior staff cascade information to junior staff. This is not Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 15 adequate to ensure all staff members with the responsibility for medication administration have the knowledge and understanding to undertake this safely. It is recommended all staff receive medication training from an outside professional that not only covers medication administration systems but also information about the medications being used. Administration of rectal diazepam is a task that must specifically delegated by a community nurse to an individual carer. Group training for administration of rectal diazepam to all service users for which this is prescribed is not acceptable for this specialised and invasive technique. Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 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): 22 and 23 The systems in place for protection from abuse do not ensure all guidelines are available, thereby placing service users at risk. EVIDENCE: The home is supported by policies and procedures on how to make and deal with complaints and allegations of abuse. The manager said the home has received no complaints since the last inspection. There has been one investigation undertaken by the home into possible financial abuse of service users monies. Sense East investigated the incident and recommendations were made to reduce the risk of further losses. However, there was no indication in the report that the service user had been reimbursed the amount missing. Although the theft was reported to the police and the Commission for Social Care Inspection, there was no referral to the Protection of Vulnerable Adults (PoVA) team. It is recommended that local guidance policies be adhered to in keeping with the Department of Health’s ‘No Secrets’ policy. Service users money and the associate financial records kept at the home were inspected. There were discrepancies in the record keeping for two service users, poor record keeping practice in three service users records and one incidence of an incorrect amount of money in a purse to the balance in the record. A staff member said she thought the incorrect amount of money in a service user’s purse could be due to a non-receipted expense. Practice in the home would be to ask staff at the time, or noted in the diary if they could remember where the missing money had been spent. Tippex was used on three service users records. This is poor practice, as it does not show the error or corrections made to the original record. Balances in two service users records had been changed, one increasing the balance with two separate reimbursements and one decreasing the balance. There was no explanation Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 17 for any of these changes or signature to show who had made the changes. Although amounts missing from service users held money are relatively small this is still considered a serious matter and the Commission for Social Care Inspection treats any discrepancy as a serious issue and this has been taken up with the provider. Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 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): 24 and 30 There were a number of serious matters which put service users at risk of serious harm and do not provide safe surroundings in which to live. EVIDENCE: The home was generally clean and tidy on the day of inspection, décor is domestic in appearance and service users are comfortable with the layout. There were no offensive odours and the risk of cross infection is reduced, as access to the laundry is away from the kitchen and eating areas. There are a number of areas in the home were service users’ health and safety is compromised. Immediate requirements have been made for work in some areas to ensure the health and safety of service users, and an action plan has been submitted to show how this will be completed. These and other areas causing concern are identified below, with additional comments. • There was a small tear in the lounge room carpet that must be repaired to ensure it does not become a trip hazard. • The laundry door could not be closed. Laundry powder, fabric conditioner and paints were not stored securely and posed a risk to service users entering the laundry. (Immediate requirements have been made.) Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 19 • • • • • • • The cleaning cupboard, storing bleach and other chemicals, was left unlocked. Tiles had been removed in the downstairs toilet/bathroom, leaving plasterwork exposed behind the sink. There were drip and water marks on the walls and clock above the bath. The toilet seat and lid were loose, making the toilet unsafe to sit on. The exit route sign in the event of a fire, located at the top of the stairs to the first floor was not securely attached. This potentially leaves service users at risk in a fire if the sign becomes detached from the wall. Tiling and plasterwork in the upstairs toilet/bathroom was cracked and chipped above the bath and along the doorframe. The floor was stained at the side of the bath. Tiling, plasterwork and grouting in the shower recess of the upstairs toilet/shower room was stained with mould, the paint was peeling and flooring was not sealed where it meets the tiled area. The floor was stained in and just outside the shower recess. There was a gouge mark in the wall where the door handle had banged. A stereo/CD player was balanced on the rim of a sink in one service user’s room. The door did not close to another service user’s room, possibly due to new carpet that had been laid. There was cracked plasterwork and paint in the corner of one service user’s room, and a light fitting without a bulb above the mirror. The light fitting should be removed if it not in use. The ceiling light in another service user’s room had no cover, a wardrobe door handle was missing and a towel hung on the wall behind the door was stained and dirty. Action should be taken by staff to ensure service users are not in danger of using soiled linen and thereby increasing the risk of cross infection. As this was only found in one area in the home a requirement will not be made at this time. One service user’s room door was propped open by a laundry bin; staff said this was because of the need for that service user to access the room using a wheelchair. The sensory room door was kept open by a magnetic hold but garden equipment was propped against the door, therefore preventing the door from closing in the event of fire. The office door was wedged open. (Immediate requirements have been made.) The home must address these issues and develop a programme of routine maintenance to ensure service users safety is maintained. Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 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): 35 The arrangements for ensuring staff training has been completed is not adequate, therefore leaving service users at risk of being cared for by staff without the knowledge to ensure all their needs can be met. EVIDENCE: Staff files and records could not be accessed during the inspection and therefore a full assessment of training could not be undertaken. A staff member said she had received induction training and annual updates of some elements of health and safety training. However, moving and handling training had not been updated since her induction training and she had not received infection control training. Service user specific training, such as diabetes and the use of blood sugar monitoring equipment, was given to the manager who cascaded the information and trained staff members. Annual training or updates for the administration of rectal diazepam had been given. All staff members must receive mandatory health and safety training at the required intervals, and training to meet the specific needs of individual service users if those staff members have the responsibility for meeting that particular need. Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42 The systems for service user consultation are limited with little evidence that service user views are sought and acted upon within the home. EVIDENCE: The manager said the last internal audit to be completed was at the end of 2004, but a report was not available in the home for interested parties. The only report for auditing and quality assurance that is available in the home is dated March 2003. However, the home undertakes regular Quality Panel meetings to discuss issues that arise. Checks are required to ensure the health and safety of service users and these must be recorded. Records were seen for fire safety checks, portable appliance testing and equipment checks. These were all recorded as acceptable, although alarm testing had not been carried out between 17/12/05 and 07/02/06. Hot water temperature checks had been completed erratically, sometimes only once a month, although all records indicated temperatures below the recommended maximum of 43oc. Accident and incident logs are kept for events occurring in the home. Checks must be completed at the Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 22 intervals required by health and safety legislation to ensure service users and staff are safe. Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 2 X X X 1 X X 2 X Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement The registered person must prepare a written plan as to how the service user’s needs in respect of his health and welfare are to be met. The registered person must keep the service user’s plan under review. The registered person must ensure that any activities in which service users participate are so far as reasonably possible free from avoidable risks. The registered person must ensure the records specified in Schedule 3 are kept securely in the care home. The registered person must maintain in the care home the records specified in Schedule 4. Records of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise. The registered person must make arrangements for service users to receive where necessary, treatment, advise and DS0000015130.V276573.R01.S.doc Timescale for action 15/04/06 2 YA9 13(4)(b) 15/04/06 3 YA10 17(1)(b) 01/04/06 4 YA17 17(2) 01/04/06 5 YA19 13(1)(b) 01/04/06 Redgate Court (38) Version 5.1 Page 25 6 YA20 13(2) 7 YA23 13(6) 8 YA24 13(4)(a), 23(2)(b), 9 YA24 (4)(c)(i) 10 YA35 18(1)(c) 11 YA39 24(1)(a), (b), (3) 12 YA42 13(4)(a), (c) other services from any health care professional. The registered person must make arrangements for the recording and safe administration of medicines received into the home. The registered person must make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. The registered person must ensure that all parts of the home to which service users have access are free from hazards to their safety. That the premises to be used as the care home are kept in a good state of repair externally and internally. The registered person must make adequate arrangements for detecting, containing and extinguishing fires. The registered person must ensure that the persons employed to work at the care home receive training appropriate to the work they are to perform. The registered person must establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home. The system must provide for consultation with service users and their representatives. All parts of the home to which service users have access are free from hazards to their safety. Unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. (Previous DS0000015130.V276573.R01.S.doc 01/04/06 01/04/06 30/04/06 01/04/06 30/04/06 30/04/06 15/04/06 Redgate Court (38) Version 5.1 Page 26 timeframe of 03/10/06 has not been met.) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA6 YA24 YA30 Good Practice Recommendations All care records should be signed and dated with day/month/year by the author of each entry. A programme of routine checks and maintenance should be commenced to identify and resolve environmental deterioration quickly. Checks should be made to ensure service users have access to clean washing materials. Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Redgate Court (38) DS0000015130.V276573.R01.S.doc Version 5.1 Page 28 - 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. 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