Inspection on 21/11/06 for Rogate

This inspection was carried out on 21st November 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Rogate 30/09/08

Rogate 06/03/06

Rogate 16/05/05

Rogate 06/10/04

Rogate 05/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Rogate 63 Surrenden Road Brighton East Sussex BN1 6PQ Lead Inspector Nigel Thompson Unannounced Inspection 21st November 2006 09:30 Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rogate Address 63 Surrenden Road Brighton East Sussex BN1 6PQ 01273 561685 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) Hallcreed Limited Ms Sandra Davis Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twelve (12). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. Date of last inspection 6th March 2006 Brief Description of the Service: Rogate is situated in a pleasant residential area of Brighton, close to local parks, shops and pubs. The home is convenient for bus services into Brighton and other areas, and Preston Park train station is also nearby. The home is registered to accommodate up to twelve people with learning disabilities; it does not provide nursing care. The building is a four-storey Edwardian house retaining some original features. The basement area has a games room and a covered hydrotherapy pool with a ramp. There are also changing and shower facilities available and a lift from these facilities to the pool. The home is fitted with ramps to enable wheelchair access, and a sloping path leads down to the pool and the large back garden where there is a barbecue area. The sitting room, dining room and some bedrooms are on the ground floor, and the home is therefore suitable for wheelchair users. Information about the service, including the Statement of Purpose, Service User’s Guide and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. The current range of fees at Rogate, as of 14 November 2006, is £624.12£1801.41 per week. Additional charges are made for hairdressing, holidays and magazines. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours in November 2006. It found that all of the key National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Service users spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. On the day of the inspection there were eleven service users living at the home. The inspection involved a tour of the premises, observation of working practices, examination of the home’s records and discussion with three service users, three members of staff and the newly appointed Care Services Manager. Responses from a CSCI service users’ survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. The focus of the inspection was on the quality of life for people who live at the home. What the service does well: Rogate is an established, well managed and well maintained service that continues to provide high quality care and accommodation for people with learning disabilities. The comfortable, relaxed and welcoming environment has evolved over many years and reflects the stability and commitment within the staff team and the open and inclusive management style. Thorough policies and procedures are in place for the admission and ongoing care and support of service users. Effective communication and consultation systems enable service users to be directly involved in developing and reviewing their individual care plans as well as many decision making processes within the home. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The comprehensive admission policy and procedure ensure that service users are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. Prospective service users know that the home is able to meet their individual care and support needs. EVIDENCE: It was noted that there have been no admissions to the home since September 2001. However recently updated information is available to prospective and existing service users in various formats. The Statement of Purpose and Service User Guide have been thoughtfully and imaginatively produced with the use of pictures and symbols and are both comprehensive and informative. In line with many of the organisational policies and procedures, the home’s admission policy, including the pre-admission assessment, is currently in the process of being reviewed and updated. The Care Services Manager (CSM) confirmed that, prior to moving into the home, prospective service users and their relatives are encouraged to visit the Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 9 home and have the opportunity to look around and meet with members of staff and existing residents. Having moved into the home, the CSM confirmed that service users undergo a ‘flexible’ trial period, during which time their suitability and compatibility are assessed and it is established whether their identified care and support needs are able to be met. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Comprehensive care plans enable staff to meet the assessed support needs of service users in a structured and consistent manner. Systems for consultation and participation are effective. Service users are treated with respect and encouraged and enabled to make decisions about their day-to-day living. EVIDENCE: Service users individual care plans that were examined contained comprehensive details of their personal, psychological and emotional support needs and were found to be accurate, up to date and generally well maintained. The CSM confirmed that the key worker system has recently been reinstated and this was evidenced through discussions with members of staff and from minutes of a recently held ‘Shift Managers’ Meeting. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 11 It was noted that revised Person Centred Plans have been implemented in respect of two service users and are currently being developed for each service user in the home. The CSM confirmed that service users and, where appropriate, a relative or advocate continue to be directly involved in regular care plan reviews. Also routinely involved in this process are the individual’s key worker from the home and their respective day services. It was evident that these reviews are recorded and plans are amended appropriately to reflect changing needs or circumstances. Following discussion with the CSM, it is recommended that the recording format be amended to include details of who attended the review. It is also recommended that individual care programmes be routinely signed by the service user or their advocate, to acknowledge agreement with the content and any changes made. Independence and individuality is evidently encouraged and promoted within the home and is reflected in the personalising of service users’ rooms, the choice of bedclothes and colour schemes and individual preferences for occupational and leisure activities. Service users are encouraged and supported to make decisions regarding many aspects of their daily living, including menu planning, what clothes they wear and how they spend their day. Staff spoken to during the inspection confirmed that, despite the variable and limited verbal communication of some service users, effective and regular interaction and consultation takes place constantly throughout the home. This was evident from direct observation of staff supporting service users in a professional, sensitive and respectful manner. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are enabled and supported to maintain contact with family and friends as they wish and effective links with the community enrich their social and educational opportunities. Service users benefit from appropriate recreational and leisure activities and menus that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: The CSM confirmed that wherever possible and appropriate, links with friends and relatives are encouraged and supported, however not all service users have regular family contact. One service user has an advocate. The recreational and leisure interests of service users are identified and recorded in their individual care plan and they continue to be supported to access activities and facilities, reflecting their individual needs, preferences and abilities. This was evidenced from care plans examined and through discussion with staff and service users. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 13 Service users spoken with during the inspection described how staffing levels impact on social opportunities: ‘It depends on how many staff are on duty. It can sometimes be boring if I can’t go out!’ All service users at Rogate attend local day centres, five days a week. They are accompanied and supported in various activities, including bowling sculpturing and reading, by care staff from the home, working on the early shift. Resources and facilities to which service users have access include a library and several computers. Menus are varied and balanced and are based on service users’ identified likes and preferences. An alternative to the main meal is always available and a copy of the menu is displayed. A member of staff confirmed that all care staff are expected to partake in cooking duties, however service users are not generally involved in meal preparation. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 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): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff have developed close and positive relationships with service users and demonstrate an awareness and sound understanding of their individual care and support needs. Service users are protected by clear and comprehensive policies and procedures in place for the control and safe administration of medication. EVIDENCE: In accordance with their care plan, service users are fully supported and enabled, as far as practicable, to exercise control over their lives and maintain maximum levels of independence and individuality. During the inspection, staff were observed interacting with service users in a professional and respectful manner. Service users spoken with during the inspection expressed general satisfaction with the care and support they receive: ‘They do ask me what I like’. ‘Staff do ask me what help I need - most of the time!’ Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 15 Documentary evidence was in place to demonstrate that the health and emotional care needs are continuing to be met within the home. All service users are registered with local GPs and have access to other health care professionals, including district nurses, physiotherapists and dentists, as required. It was noted, in care plans that were examined, that all appointments with, or visits by, health care professionals are recorded. Up to date and detailed policies and procedures relating to the control, storage, administration and recording of medication are in place. Medicines are stored and recorded appropriately. The CSM confirmed that only senior staff have responsible for administering medication and all have received appropriate training and are individually assessed and authorised to do so. This was confirmed through discussions with staff and supported by training records examined. Of concern on the day of the inspection was the unsatisfactory situation relating to the administering and recording of medicines in respect of a service user who had recently returned from holiday. Inadequate details of what medication had been administered resulted in discrepancies between the Monitored Dosage System (MDS) and the Medication Administration Record (MAR) sheet. The CSM took immediate action to address these matters and confirmed that she is to formally complain to the providers of the holiday accommodation, regarding the action of their staff and the discrepancies identified. Following this incident and subsequent complaint to the holiday placement, a written response was received by the home and a satisfactory outcome was achieved. Following discussion with the CSM, it is recommended the current situation regarding the ordering and control of medication in the home be reviewed and responsibility be transferred from a senior Home Care Support Worker to the CSM. The CSM confirmed that, following risk assessments, no service user currently self-administers their own medication. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home’s complaints procedure ensures that service users, staff and visitors feel able to express any concerns, confident that they will be listened to and acted upon. Service users are protected, through policies and procedures relating to abuse and adult protection. EVIDENCE: A copy of the home’s complaints procedure is in place in the entrance hall for the benefit of service users’ relatives and other visitors to the home. Following discussion with the CSM, it is recommended that the policy and procedure be reviewed and amended to include updated contact details for the CSCI. All complaints are recorded and include actions taken and outcomes achieved. Regular service users’ meetings provide an opportunity for concerns to be raised and discussed before they become complaints. Service users and members of staff, spoken with during the inspection, confirmed that they would have no hesitation in speaking to the manager or making a complaint if necessary and each person was confident that they would be listened to. The organisation has produced detailed policies and procedures relating to adult protection and abuse, including a whistle blowing policy. However, as previously documented, it is understood that these documents are currently Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 17 being reviewed and updated by the CSM, as part of a ‘general overhaul’ of policies and procedures within the home. The CSM confirmed that within the past month staff have undertaken specific adult protection training, in accordance with the multi agency guidelines for the protection of vulnerable adults. This was supported through discussions with members of staff during the inspection and evidenced through individual training records. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The service is accessible, safe and clean and remains clearly suitable for it’s stated purpose. Service users benefit from all necessary specialist equipment and pleasant accommodation that is comfortable, well maintained and decorated to a satisfactory standard. EVIDENCE: Other than routine redecoration and refurbishment, including the ground floor bathroom and toilet, it is evident that there has been little change in the physical environment of the home since the previous inspection and standards remain generally satisfactory throughout. During my ‘guided tour’ of the premises, including service user accommodation and spacious communal areas, it was evident that the well maintained décor and adequate furniture and furnishings continue to provide a comfortable, pleasant and homely environment for service users. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 19 The CSM confirmed that independence and individuality continue to be promoted within the home and this is evident from the personalising of service users’ individual rooms, which clearly reflects individual tastes and interests. Following discussions with the CSM, it is recommended that a screen be provided in a shared room to ensure the privacy and dignity of one of the service users with evident and increasing personal care needs. It is also recommended that building materials, including tiles and adhesive, be removed from the ground floor bedroom, where they are currently being stored. It was noted that infection control policies and procedures are in place and clearly adhered to. Levels of cleanliness remain satisfactory throughout. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There is always sufficient trained and competent staff on duty to meet the assessed needs of the service users. Service users are protected by satisfactory staff recruitment policies, procedures and documentation. EVIDENCE: In addition to the comprehensive induction programme undertaken by all newly appointed staff, the CSM confirmed that appropriate core skills training is provided, including first aid, moving and handling, food hygiene and fire safety. This was confirmed through discussions with the training co-ordinator and care staff and supported by training records examined: ‘There is always plenty of training here!’ There are currently seven members of staff who hold the National Vocational Qualification (NVQ) level 2 or above, in care. This represents almost 50 of all care staff in the home. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 21 A training matrix on display in the office highlights courses and specific training attended by staff and identifies any shortfalls and individual training needs. Following discussions with the CSM and training co-ordinator, it is recommended that the matrix be reviewed and amended to include dates of specific training and to ensure that information recorded is both accurate and up to date. The CSM is clearly aware of the need for thorough and robust recruitment procedures, to ensure the protection of service users. Individual files that were examined, relating to recently appointed members of staff, were found to be well maintained, containing all relevant and necessary information, including two satisfactory references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. As previously documented, the CSM has only been in post for three months and she confirmed that she is still in the process of implementing a structured programme of formal staff supervision within the home. She has begun the process of supervising shift leaders who in turn are each expected to provide formal supervision to two Home Care Support Workers. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from a competent and experienced manager and are protected by satisfactory health and safety procedures. Their best interests are safeguarded by adequate and effective quality monitoring systems. EVIDENCE: The CSM was appointed to her current post in August this year. Although she is yet to commence studying for the NVQ level 4, in Management and Care or the Registered Manager’s Award (RMA), she is a qualified and experienced social worker, has managed a day centre for adults with learning disabilities. As a Practice Manager she later had overall responsibility for seven day services. She and has also worked as part of the Community Mental Health Team (CMHT). Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 23 In addition to the management of Rogate, she oversees the running of three other residential services and a day centre within the group and has responsibility for the supervision of the respective service managers. She confirmed that her application to become the registered manager at Rogate has been submitted and is currently being processed by the CSCI. The home continues to operate effective quality monitoring systems, including regular satisfaction questionnaires for service users. As part of a major review of the home’s policies and procedures the CSM confirmed that she is to develop and implement a structured survey to obtain the views of stakeholders and service users’ relatives. The CSM confirmed that the health, safety and welfare of service users and staff remains of paramount importance within the home. Staff training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. All staff training is recorded. It was noted that all radiators throughout the home are fitted with protective covers, as necessary. COSHH assessments and guidelines are in place. Comprehensive fire safety risk assessments are in place. Regular fire drills are undertaken and recorded. However it was noted that there are gaps in the recording of checks for the fire alarm system and emergency lights. This was brought to the attention of the CSM who is to ensure that regular checks be carried out and recorded appropriately. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and generally reported, as required. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 2 X X 3 X Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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. 2. Standard YA37 YA36 Regulation 9 (2) (b) (1) 18 (2) Timescale for action It is required that the manager is 30/06/07 suitably qualified to manage a residential care service. It is required that all care staff 30/03/07 receive regular and recorded formal supervision. Requirement 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 YA6 YA6 Good Practice Recommendations It is recommended that the recording format for care plan reviews be amended to include details of who attended the review and in what capacity. It is recommended that individual care programmes be routinely signed by the service user or their advocate, to acknowledge agreement with the content and any changes made. It is recommended that responsibility for the ordering and control of medication within the home be transferred from the Director to the CSM. It is also recommended that building materials, including tiles and adhesive, be removed from the ground floor bedroom, where they are currently being stored. DS0000014230.V315351.R01.S.doc Version 5.2 Page 26 3. 4. YA20 YA24 Rogate 5. YA26 It is recommended that a screen be provided in a shared room to ensure the privacy and dignity of one of the service users with evident and increasing personal care needs. Rogate DS0000014230.V315351.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Rogate DS0000014230.V315351.R01.S.doc Version 5.2 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. 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!