Inspection on 28/11/05 for Repton Drive

This inspection was carried out on 28th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 29 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Repton Drive 22/11/07

Repton Drive 07/12/06

Repton Drive 09/05/06

Repton Drive 06/09/05

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Repton Drive 13a Repton Drive Gidea Park Romford Essex RM2 5LP Lead Inspector Ms Edi O`Farrell Unannounced Inspection 28th November 2005 12:40 Repton Drive DS0000060783.V268387.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 Repton Drive DS0000060783.V268387.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. Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Repton Drive Address 13a Repton Drive Gidea Park Romford Essex RM2 5LP 020 8308 2900 020 8308 2999 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) The Avenues Trust Limited Miss Ruth Wilcox Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: 13a Repton Drive is a six place care home for adults with severe learning and physical disabilities, situated in a residential part of Romford. Opened in December 2004, it is a purpose built bungalow set behind detached houses, a short walk from bus routes into Romford town centre. There are six, single, bedrooms, each with ensuite toilet, shower, and wash hand basin. There is an additional communal shower, and bathroom. The kitchen/diner is domestic in nature, as is the utility room. A conservatory has been added, which is accessed via the lounge, and this adds to the communal space, which was insufficient for six service users. There is parking to the front of the building, and a small enclosed garden to the rear, which is due to be landscaped. The home provides 24-hour personal care, with health needs being met by visiting professionals, or staff accompanying service users to outpatient clinics. All areas of the home have full disabled access, and two bedrooms have fixed overhead tracking for specialist hoists. The Avenues Trust, a private company, which operates other similar homes in the area and in Kent, runs the home. The home is currently developing Person Centred Planning, in line with ‘Valuing People’, the national policy for people with learning disabilities. There are currently three service users living in the home, with a fourth visiting during day time hours at the weekends. Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This, unannounced, inspection took place on a weekday during the early afternoon. The main focus was to check on progress in relation to 14 Requirements set at the previous inspection, and to assess one core standard not covered at that visit. In addition current staffing arrangements were looked at, and discussed with the manager, who is new in post since the last visit. Records such as care plans, accident reports, and rotas were examined, and some aspects of care were discussed with some staff. The three current service users are mainly non-verbal, so obtaining their views is difficult, though they were observed, both directly and indirectly, interacting with staff. The inspection also took into account concerns about the quality of care provision which have been the subject of discussions between the Commission for Social Care Inspection, the London Borough of Havering and Avenues Trust. This was the second statutory inspection in the inspection programme for 2005/6. Over the course of the two visits, all core standards have now been assessed. The timescales for completion of some of the Requirements set at the previous inspection have not yet been reached, so these have been brought forward in this report with the original timescales. Other Requirements have not been met within the set timescale, and these have been restated, with a new timescale. Dates in bold denote this. Further information about unmet Requirements can be found in the relevant standards. Unmet Requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. What the service does well: What has improved since the last inspection? Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 Page 6 The building of a conservatory, accessed via the lounge, has been completed. This will add to the communal space, as the lounge is too small for six service users. A new manager has started, and has identified what the most urgent things to do are. This is the reassessment of the current service users’ needs and setting up of new care plans, as well as sorting out some complex staffing problems. This process has already resulted in greater attention to the reasons why one service user acts in certain ways. This should mean that, over time, things that might provoke distress will be identified, and removed. Three new members have been drafted in from other homes in order to strengthen the leadership of shifts. This will mean that the manager can sort out the other things quicker. Staff are now making sure they always follow correct procedure in relation to medication, this means that service users are better protected from possible mistakes. Alternative ways of responding to negative behaviour by one service user are continuing to be used. This has greatly reduced the need for extra medication for him. Likes and dislikes for activities are being more closely monitored, resulting in service users doing more things that they like. The manager is arranging for parts of the building to be decorated, and had bought new pictures for the walls, to try and increase the homely feel of the place. What they could do better: The home has gone through a very difficult time, both prior to, and, since the last inspection. This has mainly been about staff raising concerns about other staff, and the way they work. This has resulted in some staff being suspended from work whilst investigations are carried out. In addition the new manager had only just started immediately prior to the last visit. Homes with a lot of problems, like this one, can take some considerable time to sort out, but the new manager is trying to address these issues. The most important areas for improvement are the completion of the assessments and person centred plans, and the building up of an effective staff team. Once both of these are in place the manager, and the company need to make sure that there are systems in place for picking up any further problems and responding to them quickly. This home has the capacity to provide a high quality service to very vulnerable people, and senior managers within the company should take the opportunity to work with the new manager to achieve this. Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 Page 7 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. Repton Drive DS0000060783.V268387.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 Repton Drive DS0000060783.V268387.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): 1, 2, 3 & 4 Work has started on the production of a Service User Guide that will be useful to prospective service users, as it will contain symbols and photographs. Prospective service users’ individual aspirations and needs are currently being assessed, using a person centred approach, so that by the time they move in comprehensive plans will be in place. Prospective service users, and their representatives, are visiting the home to ‘test drive’ the service, so that their eventual move is as smooth as possible. EVIDENCE: The Statement of Purpose and the Service User Guide were examined. As at the last inspection the former had several inaccuracies, and the latter was not completed. Some minor alterations are still required to the Statement of Purpose; as the manager has this in hand no Requirement has been set. The Service User Guide is complete apart from the inclusion of photographs, such as of the various rooms, and of the current service users. As they are unable to give informed consent for this, the inclusion of photographs of service users must be fully discussed with their next of kin, and the placing authority. This is Requirement 1. Requirement 2 has been brought forward from the previous report, as the timescale has not yet been reached. There are currently two prospective service users, who are visiting the home on a regular basis, so that by the time they move in their needs should be fully met. Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 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, 9 & 10 Service users’ needs are currently being re-assessed using a person centred approach, which, once completed and fully implemented, will meet their needs and aspirations. In the interim some needs could be missed due to the recording and filing system. Two Requirements set at the previous inspection relating to assessment and care planning have not yet been met. Service users are supported to take risks, and the improvement in this aspect of care noted at the previous inspection has continued. This needs to be built on further by comprehensive and robust risk assessment. EVIDENCE: The home provides a service for very severely disabled adults, two of whom spent many years living in hospital. Prior to admission comprehensive assessments were carried out by the multi-disciplinary team, including community care assessments. These are available on file, and the information is being used to complete person centred plans. Three sets of care records were looked at in depth at the previous inspection, with one being rechecked during this visit. Whilst some work has been done, the assessments, including risk assessments have not yet been completed. The completion of the assessments and development of comprehensive care plans, that are working Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 Page 11 documents for staff, is a priority. They must be completed within the new time scales set for Requirements 3 and 4. At the previous inspection it was noted that the use of PRN medication to control destructive behaviour by one service user had recently reduced, as staff were using a diversionary approach. This has been continued, and built on, by on-going assessment of this behaviour, to try and identify any patterns. This is the level of detailed work that is required for this service user group. Please refer to Requirement 1 and the comments in the previous section of this report regarding the use of service users’ photographs as this relates to Standard 10. Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 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): 11, 12, 13 & 14 Service users have opportunities for personal development, and take part in appropriate activities within the home and the local community. Staffing levels now allow for a more consistent approach to each service user’s preferred lifestyle. EVIDENCE: Each service user has an individual weekly activity programme. This includes going shopping, to the cinema, pub, restaurants and use of sensory equipment within the home. At the previous inspection it was noted that these activities were sometimes curtailed due to lack of staff. Examination of the staff rota, daily logs, and service users’ financial transactions demonstrated that there is now sufficient staff for regular activities. The manager was able to demonstrate that the appropriateness of each activity was being monitored on a daily basis, and the programmes amended accordingly, for example, one service user had demonstrated by their behaviour that they did not like going to the cinema. This activity had therefore been stopped, and another put in its place. The range of activities should increase even more once the more detailed person centred plans are in operation. Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 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, 19, 20 & 21 Service users generally receive personal and health care support in the way they prefer and require, and their physical, emotional, and health needs are generally met. The person centred plans needs to be finalised and put into operation in order to be sure that is always the case. Staff are now following correct procedure in relation to medication administration, offering fuller protection to service users. EVIDENCE: Please refer to the comments under the ‘individual needs and choices’ section of this report and to Requirement 3. Three Requirements were set at the previous inspection in relation to medication administration. A check of the medication cupboard and sampling of the charts and prescriptions demonstrated that these have been complied with. A specialist pharmacist inspection was carried out immediately following the last inspection, and those Requirements and Recommendations will be checked on separately. In response to a Requirement set at the previous inspection two staff members have attended a loss and bereavement course, and others are booked to attend. Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 Page 14 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 & 23 Service users may not have been fully protected from abuse over recent months, but senior management have now taken steps to address this. This needs to be built on so that all staff are clear that a zero tolerance policy in response to abuse, including bad practice, is operated in the home. EVIDENCE: There is currently a police-led adult protection investigation in progress, plus two in-house investigations in response to whistle blowing. These have resulted in four members of staff being suspended. During the week prior to the inspection an Adult Protection Strategy meeting was held, attended by Havering Social Services, including the Adult Protection Co-ordinator, the Commission, and The Avenues Trust. An action plan was agreed that all felt would provide extra protection. The main focus of the action plan was the need for experienced shift leaders who have not been part of the staff team over the past 12 months. This was to be in place for the Friday preceding this inspection, and the arrangements were checked during the visit. The manager, a manager from another home, and a service manager had covered the weekend. Three members of staff from other homes operated by the Trust have been drafted in and will remain working at the home until the staff team is stabilised, and all concerned can be assured that the service users are fully protected. The manager reported that the relevant policies and procedures, such as whistle blowing, adult protection, and risk assessment and management will be discussed on a regular basis in handover. This is Requirement 5, and is commented on further in the staffing section of this report. Requirement 6 has been brought forward from the previous report as the timescale has not yet been reached. There have been no recorded complaints since the last inspection, apart from those raised by staff as part of whistle blowing on alleged abusive incidents. Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 Page 15 As the service users are unable to realistically use a complaints procedure staff have a crucial role in raising them on their behalf. Requirement 5 has therefore also been linked to Standard 22. Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 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 & 30 Some attention to decoration and furnishing is needed in order to make the home as comfortable as can be. The manager is already attending to this. Once functional, the new conservatory will add much needed communal space. The home was clean and hygienic. EVIDENCE: The communal parts of the building were toured, and some bedrooms seen from the corridor. The manager reported that the reception area and main corridor is going to be redecorated, and had a written estimate for this work. She also reported that she had purchased some more paintings for the walls, and that new covers for the settees were on order. The conservatory is now completed, apart from a radiator cover, blinds, and furniture. The extra communal space had to be added on as the lounge is too small for six service users. It will need to be inspected by a registration inspector in order to complete the registration. This is Requirement 7 All parts of the home seen were clean and tidy, and staff spoken to were aware of hygiene requirements. The manager is currently looking into how the environment could look clean and well-care for more easily, for example, currently the walls have some scuff marks on them, as the paint is not Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 Page 17 washable. Carpets have been deep cleaned, but not all marks can be got out, suitable alternatives are being looked at. The manager is aware that the service users’ behaviour can at times take a heavy toll on the environment, and that a yearly repair, maintenance, and decoration programme needs to be in place. This is Requirement 8. Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 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, 33, 34, 35 & 36 Whilst individual staff members can demonstrate a commitment to meeting the needs of service users, effective team working has been badly affected by a lack of leadership. Some staff may not have felt able to voice concerns and this may have had an adverse impact on the support and protection given to service users. The providers operate a robust recruitment procedure. EVIDENCE: Requirement 9 has been brought forward from the previous report, as the timescale has not yet been reached. In the period leading up to, and since that inspection the home had been experiencing several problems that are often associated with the absence of a manager, combined with a relatively new staff team. This included poor record keeping, poor communication, lack of knowledge of service users’ needs, and absence of care plans. In response, a service manager was working at the home, and had made some improvements, such as the introduction of shift plans. A new manager had also been appointed, who has made further improvement, which are commented on in the next section of this report. Since the last inspection the situation has worsened, with some staff whistle blowing, and others using anonymous letters to make allegations against their colleagues. If these allegations are proven they raise serious concerns about how all staff understand their responsibilities to service users. If they are not proven, they Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 Page 19 raise serious concerns about the functioning of the staff team over a period of several months. There are currently four members of staff suspended, pending the outcome of investigations. This has left the home with only five permanent support workers, two of whom are part time. Agency and bank staff have very often covered shifts, and whilst some know the service users well, others do not. The staffing situation was discussed in depth with The Avenues Trust during the week preceding this inspection. As stated earlier in this report it was agreed that experienced shift leaders from other projects would be drafted in. This was felt to be necessary so that there was always a person in charge who had not been a part of the staff team during the period that the allegations, and counter allegations relate to. Two of these members of staff were on duty during the visit and were clear as to their role. This arrangement must continue until the Commission is satisfied that service users are protected at all times by competent staff who work effectively as a team, to meet service users’ needs. This is Requirement 10. The manager reported that the handover period will be used, in conjunction with staff meetings and supervision, to develop the staff team. This will include discussion of key policies and procedures, such as adult protection, and care planning. Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 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, 41, 42 & 43 The new manager has a considerable amount of work to do to raise the standard of this home. There are already positive signs of her capability to do so, so that ultimately service users benefit from a well-run home, in which they are safe, and their best interests are put first. The company need to implement a robust quality assurance, and quality control, system, which identifies potential problems at an early stage, and then to take remedial action to solve them. EVIDENCE: Records were examined and discussed with the manager, as were the recent events referred to in the previous section of this report. The manager is currently being registered by the Commission, but does not hold a management qualification. This was discussed as the deadline for demonstrating to the Commission that steps have been taken to meet the target date of 31 December 2005, is that date. This is Requirement 11. Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 Page 21 The manager, who has been in post since September, was able to demonstrate where she has already taken action to stop work practices that are not in the best interest of service users. Examples are, stopping the practice of staff using different crockery than service users, and of making changes to the rota without recourse to her. She also demonstrated an ability to prioritise such things as risk assessment and care planning. The strengthening of the staff team by the introduction of the three new workers should free up her management time to effect these needed changes. The manager must receive appropriate support in order to make the required changes; this is Requirement 12. As stated in the last report the Commission, and the placing authority, have concerns about the adequacy of the system used by the company to monitor the quality of the service provided. This had been discussed directly with the company, who were introducing a new system. In recognition of this no Requirement was set in the last report. This system has not yet been implemented so Requirement 13 has been set. Requirement 14 relates to the lack of working knowledge that some staff appear to have about the correct procedures to follow when concerned about colleagues working practices. Health and safety records are, in the main, good and up-to-date, but the Requirement set at the previous inspection, for fire drills to be held, has not yet been actioned. It has been brought forward as Requirement 15 with a new timescale. Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 X Standard No 22 23 Score 1 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 1 1 1 3 1 1 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Repton Drive Score 2 2 3 3 Standard No 37 38 39 40 41 42 43 Score 2 1 1 1 X 2 1 DS0000060783.V268387.R01.S.doc Version 5.0 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 YA1YA10 Regulation Requirement Timescale for action 31/12/05 2 YA1 3 YA6YA9YA18YA19 4 YA9 5 & 12 (4) Where photographs (a) of service users are used in documents, such as the Service User Guide, this must be with their permission. Where it is not possible for them to give this, due to limited mental capacity, their next of kin, and the placing authority must be asked for their views. 5 The Service User 31/12/05 Guide must be made available to service users in a format that is suitable for them. 31/12/05 12, 13 & Care plans must be 15 comprehensive and be available to staff so that all needs are met on a day-to-day basis. Previous timescale of 31/10/05 not met. 13c & 15 Care plans must 31/12/05 DS0000060783.V268387.R01.S.doc Version 5.0 Page 24 Repton Drive 5 YA22YA23 13 (6) & 22 6 YA23 13 (6) 7 YA24 23 8 YA24 23 9 YA31YA32YA33YA35YA36 18 include full risk assessment and risk management plans for all identified risks. When new risks are identified these must be incorporated into the plans. Previous timescale of 31/10/05 not met. The Registered Person must ensure that the staff team are equipped to recognise potential abuse, and that they are clear as to their responsibilities. Staff must report any potentially abusive practices immediately. All staff must have attended training on the protection of vulnerable adults. The Registered Person must inform the Commission once the conservatory is ready to be used, so that a site visit can be organised. There must be an annual programme of repair, maintenance, and decoration, that takes account of the level of wear and tear that arises with this service user group. The Registered Person must ensure that all staff working 31/12/05 31/12/05 30/01/06 30/01/06 31/12/05 Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 Page 25 10 YA31YA32YA33YA35YA36 18 11 YA37 8 12 YA38YA43 12 13 YA39 24 in the home have the appropriate training for the job that they are expected to do. This must include skills to work in a newly formed staff team and new project. The Registered Person must ensure that the home is staffed at all times with competent staff who work effectively as a team. Shift leaders must understand their roles and responsibilities. The manager must provide evidence to the Commission that she is actively seeking to register for the RMA. The Registered Person must ensure that the manager of the home receives consistent and appropriate support so that she can make the changes that are necessary in order to ensure that it becomes a wellrun home, where the best interests of service users are put first. There must be effective quality monitoring and quality assurance systems in place. These must be capable of 28/11/05 31/12/05 28/11/05 31/03/06 Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 Page 26 14 YA40 12 & 13 15 YA42 23 (4) identifying problems at an early stage, in order that remedial action can be taken. All staff must 28/02/06 understand, and work to at all times, the home’s policies and procedures. The Registered 31/12/05 Provider must ensure that regular fire drills are carried out and recorded. Previous timescale of 31/10/05 not 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. Refer to Standard Good Practice Recommendations Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Repton Drive DS0000060783.V268387.R01.S.doc Version 5.0 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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