Inspection on 02/08/07 for Roman Court (1)

This inspection was carried out on 2nd August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Roman Court (1) 18/08/09

Roman Court (1) 12/07/06

Roman Court (1) 01/03/06

Roman Court (1) 20/09/05

Roman Court (1) 17/03/05

Roman Court (1) 14/10/04

Roman Court (1) 23/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Roman Court (1) 1 Roman Court Broadfields Pewsey Wiltshire SN9 5DS Lead Inspector Elaine Barber Key Unannounced Inspection 2 August and 5 September 2007 10:25 nd th DS0000028114.V336506.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 DS0000028114.V336506.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. DS0000028114.V336506.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roman Court (1) Address 1 Roman Court Broadfields Pewsey Wiltshire SN9 5DS 01672 564412 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) Steven@StevenAbbott.wanadoo.co.uk Mrs Jane Abbott Mrs Carol Bottoms Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000028114.V336506.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th July 2006 Brief Description of the Service: Valued Lives is a private organisation, which operates five care homes for adults with a learning disability. All are small establishments, intended to offer a normal domestic lifestyle. The main lead for the organisation is taken by one of the registered person, Mrs Jane Abbott. She is supported by other senior colleagues, including family members. Each of the Valued Lives homes is situated in Pewsey, or nearby small villages. Pewsey itself offers a range of amenities. The market towns of Marlborough or Devizes are within 15 minutes’ drive. Slightly further afield, there are the larger centres of Salisbury and Swindon. The organisation has a number of vehicles used to transport people, who contribute towards the costs of these. Most people now cared for by the organisation have been with them for a number of years. People may have lived in more than one of the homes that Valued Lives operates. Roman Court is on a housing estate in Pewsey. The home cares for up to three people. Each person has a single room. There is an upstairs bathroom, and a separate toilet downstairs. There is also a living room, dining area and kitchen downstairs. There is an enclosed garden area at the back of the house. The current fees range from £636 to £745. DS0000028114.V336506.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included two visits to the home on 2nd August and 5th September 2007. The visit on 2nd August was unannounced. During the visits information was gathered using: • • • • • Observation Discussion with one of the people who lived in the home Discussion with staff Discussion with the manager Reading records. Other information and feedback about the home has been received and taken into account as part of this inspection: • The manager provided information prior to the inspection about the running of the home. The judgements contained in this report have been made from all this evidence gathered during the inspection, including the visits. What the service does well: Each person had their needs assessed over a period of years to ensure that their needs would be met. They also had a contract with the home which contained their terms and conditions and the fees. People had their abilities, needs and goals reflected in their individual plans which were being updated. This would ensure that their needs continued to be met. They were supported to make choices and decisions in their daily lives. Risks in daily living were assessed and action was taken to reduce risks and promote independence. People were supported to take risks and access opportunities. People were provided with a range of activities and opportunities to engage with their local community. They went to a day service run by the organisation. They went shopping, played skittles, went for walks, went to the pub, went out for meals and went on holiday to a caravan. Activities were suited to their individual needs and preferences. DS0000028114.V336506.R01.S.doc Version 5.2 Page 6 People were able to maintain and develop appropriate relationships with family and friends. They met people through the day service and visited people in the other houses run by the organisation. Both people regularly visited their family and went on holiday with them. People participated in the routines of the home and were involved in the cleaning, cooking and washing. Their daily lives had an appropriate balance between necessary routines, and individual choice. People chose their meals using menu cards and were involved in meal preparation. Special diets were catered for. People were offered a varied diet and enjoyed their meals. People received personal support in the way that they preferred and required. People’s emotional and physical health needs were being met. They had access to a range of different health care professionals. Medication was appropriately stored and recorded. People were protected by the home’s policy and procedures for dealing with medication. People are safeguarded by the home’s policies and procedures for complaints and protection. There was a complaints procedure and there had been no complaints since the last inspection. There was a policy about protection from abuse and staff had received training, which they kept up to date. People are protected from abuse, neglect and self harm. People lived in a comfortable, clean and safe environment, suitable to their needs. The accommodation was well maintained, decorated and furnished. People had chosen the décor and furniture. The house was clean and hygienic. There was always one member of staff on duty and one member of staff slept in at night. A range of training was provided for staff who kept their training up to date. One member of staff who worked in the home had a National Vocational Qualification (NVQ) at level three. One member of staff had just completed NVQ level 2 and was waiting fro their certificate. People were supported by an effective staff team, who were appropriately trained, competent and qualified to meet their needs. There was a recruitment procedure and the standard about recruitment was met at the last inspection. No staff had been recruited since. People were protected by the home’s recruitment practices. The owner and manager were appropriately qualified and experienced to run the home. They were supported by other senior managers in the organisation so that people were generally benefiting from a well run home. There was a range of health and safety measures to ensure that the environment was safe for the people who lived there and the staff. People’s health, safety and welfare were promoted and protected. DS0000028114.V336506.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. DS0000028114.V336506.R01.S.doc Version 5.2 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 DS0000028114.V336506.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs were assessed so that their needs could be met. Each person had a contract and individual terms and conditions with the home. EVIDENCE: There had been no recent admissions to the home. Both people at Roman Court had lived within Valued Lives for a number of years. They had therefore established their routines and their individual and varied needs had been assessed over time. There had also been continuity and stability in the staff team. Many had several years’ experience. This had given them a depth of knowledge regarding people who lived at Roman Court. Both people had contracts with Valued Lives which set out their terms and conditions and fees and social services’ contribution. DS0000028114.V336506.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People had their abilities, needs and goals reflected in their individual plans which were being updated. They were supported to make choices and decisions in their daily lives. People were also supported to take risks and access opportunities. EVIDENCE: Each person had a very detailed care plan to meet all their individual assessed needs. These had become out of date and a new care plan format was being introduced. The care plan format included generalised information about needs such as accommodation, safety and protection, independence, medication and physical well being. The manager said that the keyworkers were working through the plans and adding information to make them specific to each person’s needs. DS0000028114.V336506.R01.S.doc Version 5.2 Page 11 Three recommendations about care planning were made at the last inspection. The plans were not yet complete. The first recommendation that care plans should be signed and dated and all changes to the care plans should be signed and dated was being addressed. They were dated but were not yet signed by the person and keyworker. The second that the service user or their representative should sign the plan was also being addressed. There were spaces for the person and keyworker to sign. There was a format for additional support guidelines, which had not yet been completed. The third recommendation that care plans should be reviewed at least six monthly was also being addressed. Staff were in the process of reviewing the care plans but care managers had not yet reviewed the plans. The records showed examples of when people had made choices and decisions about their lives. Examples included choosing to spend time in their own rooms or the living room watching TV and choosing their daytime activities. Both people had chosen the colours for their bedrooms which were decorated last year. Each person had risk assessments for all aspects of their lives and these were signed and dated. These focused on promoting independence and included action taken to minimise risks. The manager said that the risk assessments were due to be reviewed and put into new files. DS0000028114.V336506.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. 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. People were provided with a range of activities and opportunities to engage with their local community. Activities were suited to their individual needs and preferences. People were able to maintain and develop appropriate relationships with family and friends. People’s daily lives had an appropriate balance between necessary routines, and individual choice. People were offered a varied diet and enjoyed their meals. DS0000028114.V336506.R01.S.doc Version 5.2 Page 13 EVIDENCE: The daily records showed that people were participating in a range of activities including household chores and gardening. They also went shopping, went to church, went to the pub, played skittles, had trips out to the garden centre, and had meals out. The two people had grown tomatoes in pots. The records showed that there was a good mix of household chores and outings. People had chosen the new carpet for the living room. They also chose the colour of their rooms when they were redecorated last year. One of the people who lived in the home was at home during the second visit. They said that they enjoyed their daytime activities. Their records showed that they had a varied day programme. They said that they did their housework and washing and went to the shops. They said that they had been playing skittles at a local pub. They said that they also went to the cinema and shopping and they went on holiday to a caravan owned by the organisation. The daily records showed that people had a range of activities at their day service. The person who was at home said that they saw their family and had visited their sister who lived abroad and were due to visit their mother, who also lived abroad, the following weekend. They talked about meeting up with friends from other houses run by the organisation. The other person was on holiday at the time of the inspection. The manager reported that this person saw their parents once a month and the records confirmed this. There was a varied menu, which reflected a balanced diet. The people planned their own menus using recipe cards to choose different dishes. They helped the member of staff on duty to cook the evening meal and they could prepare their own drinks and snacks. One person required a special diet and this was catered for. The person who was at home was eating their evening meal and said that they enjoyed it. DS0000028114.V336506.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. 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. People received personal support in the way that they preferred and required. People’s emotional and physical health needs were being met. People were protected by the home’s policy and procedures for dealing with medication. EVIDENCE: People were assisted with various levels of personal care and supervision depending on their individual abilities. People had established routines, such as their preferred time for getting up. Their daily routines were recorded in their care plans and daily notes. Assistance was given to choose clothes on a daily basis. Each individual had an allocated keyworker who organised shopping trips with people to purchase new items. Part of their responsibility was to ensure that people had sufficient clothes and toiletries. Valued Lives had a policy regarding people receiving personal care from someone of the opposite gender. This provided suitable safeguards for both people who lived in the home and staff. DS0000028114.V336506.R01.S.doc Version 5.2 Page 15 There was a strong focus on health promotion and responding to any needs that arise. People received regular health monitoring including dental and optical check ups. Any specialised services, such as speech therapy or occupational therapy, were accessed as required. Visits to healthcare professionals were recorded including the GP, consultant, chiropodist, nurse, continence advisor, optician and dentist. All appointments were undertaken in private, although a staff member would give assistance as needed. There was a policy about medication. Medication was stored and recorded appropriately. Staff had received training in medication handling. There were records of medication received into the home and administered. There was a record sheet of when medication was returned to the pharmacist. Changes to medication were recorded and signed. A record was also made when a person took medication out of the home, for example when visiting relatives. There was sheet in the front of the medication book, which explained the reason for giving medications, which were only used occasionally. DS0000028114.V336506.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. 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. People are safeguarded by the home’s policies and procedures for complaints and protection. People are protected from abuse, neglect and self harm. EVIDENCE: There was a complaints procedure including how to complain and the timescales for dealing with complaints. There had been no complaints made to the organisation and no complaints had been received by CSCI. The person who was spoken to said that they knew who to talk to if they wanted to make a complaint. There was a wide range of information about adult protection issues. This included details about multi-agency procedures within Wiltshire. A ‘Protection’ section in each individual’s old style care plan gave information about the various safeguards in place. These include recruitment checks, staff training, and key individual abilities and relationships that contribute to upholding someone’s welfare. There was also a safety and protection section in the new style care plan but this section still needed to be completed for each person. Staff had received training about prevention of abuse. This had been updated at the end of last year. There had been no allegations of abuse. DS0000028114.V336506.R01.S.doc Version 5.2 Page 17 The local community learning disability nurse had helped the staff to develop some behaviour management guidance. Physical interventions could be used with some people on occasions. Individual guidelines described the holds, which may be used. Staff had received appropriate training in these techniques. Staff helped people to manage their money and appropriate records were kept. DS0000028114.V336506.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People lived in a comfortable, clean and safe environment, suitable to their needs. EVIDENCE: Roman Court is a modern semi-detached house, in a residential estate in Pewsey. It is a short walk from the centre of the village, and all local amenities. The home is domestic in scale and in keeping with other houses in the street. It is attractively decorated and furnished. There was ongoing renovation, when required. As part of this process, all windows had been replaced the previous year. The home had been redecorated since the last inspection. The lounge had been wallpapered and a new carpet had been laid. The people had chosen the colour. DS0000028114.V336506.R01.S.doc Version 5.2 Page 19 Both bedrooms had been redecorated and the people had chosen the colours for their rooms. The bedrooms were individually furnished and personalised. The person who was spoken to said that they were pleased with the redecoration and furnishing of their room. There was a small dining and seating area next to the kitchen. The laundry facilities were domestic in style. There was a washing machine in the kitchen and a tumble drier in the garage. The person who was spoken to said that they did their own laundry. A cleaning company cleaned the house once a week. The home appeared clean and hygienic in all areas seen at this unannounced inspection. DS0000028114.V336506.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were supported by an effective staff team, who were appropriately trained, competent and qualified to meet their needs. People were protected by the home’s recruitment practices. EVIDENCE: Roman Court had three main staff who worked most of the shifts. Since the last inspection one member of staff had left and additional cover was provided by other staff in the organisation and a member of staff from an agency. There was usually one person on duty. When people went out to their planned activities, this person went with them. At nights, one person slept in. An oncall manager was available, if required. One of the regular members of staff had a National Vocational Qualification (NVQ) at level two. The newest member of staff had completed NVQ level 2 and was waiting for their certificate. DS0000028114.V336506.R01.S.doc Version 5.2 Page 21 There was a range of training provided and staff kept their training up to date. The staff had refresher training in November 2006 for health and safety, fire safety, physical intervention, first aid and administration of medicines by special methods. Food hygiene training was planned for September 2007. The standard about recruitment was met at the last inspection and no new staff have been recruited since. DS0000028114.V336506.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area was generally good although further work was needed on quality assurance. This judgement has been made using available evidence including a visit to this service. The registered manager was suitably competent and experienced and on the whole people benefited from a well run home. The home was not providing evidence that they took responsibility for their own quality assurance and that people’s views underpinned all self-monitoring, review and development by the home. People’s health and safety were protected by the systems in place. DS0000028114.V336506.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered person for Valued Lives was Mrs Jane Abbott. She had lengthy experience of working with people with a learning disability, and had owned and operated her own services for many years. She was supported by other senior staff within the organisation. Together, they oversaw all five services run by Valued Lives. The registered manager was Mrs Carol Bottoms. She had almost completed the registered managers award and kept her training up to date. For the last two inspections the registered manager had been working on their quality assurance for the service. The quality assurance framework was based on the systems in the house including policies and procedures, care plans, records and staffing. A consultant had provided advice and guidance about quality assurance. The views of people who used the service, relatives and visiting professionals had been collected. These had been collated into a quality assurance report for the whole service covering five homes. There was also a draft review report of the previous three years. Areas for improvement were identified. At the last inspection the owner reported that they needed to complete the summary of what had taken place over the last three years and type up the goals for the next three years. It was also identified that a copy of this report needed to be finalised, sent to the Commission and made available to all people who used the service. A requirement was made and this had not been addressed. The annual quality assurance process was due to be started again by collecting the views of people who lived in the home. The service manager reported that there were no plans to do this. There was a health and safety policy to comply with the relevant regulations. A number of general risk assessments and safe working procedures had been recorded. There were also individual risk assessments. There were arrangements for the training of staff in moving and handling, fire safety, first aid and food hygiene. A monthly ‘hazard’ inspection of the home was carried out. Hot water temperature regulators had been fitted to the taps. Water temperatures were taken monthly. The two people who lived in the home could regulate the temperature of their own bath water. There were COSHH assessments, equipment was regularly serviced and portable appliances were tested annually. There was a fire risk assessment and records of fire safety checks. The radiators were not covered. Each person had an individual assessment of the risks posed by radiators which identified that they did not pose a risk. Information was available about what to do in the event of a heat wave. DS0000028114.V336506.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 X 2 3 3 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 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 3 X 2 X X 3 X DS0000028114.V336506.R01.S.doc Version 5.2 Page 25 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 YA39 Regulation 24 Requirement The registered person must supply to the Commission a copy of the report about the quality assurance survey and make a copy of the report available to service users. (The timescale of 30/09/06 had not been met.) The registered person must continue to implement an effective cycle of quality assurance and ensure that the views of all stakeholders are represented. Timescale for action 31/12/07 2. YA39 24 28/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 YA41 Good Practice Recommendations Care plans should be signed when they are developed. All changes to the care plans should also be signed and dated. (New care plans were being developed but the process was not yet complete.) DS0000028114.V336506.R01.S.doc Version 5.2 Page 26 2. 3. YA6 YA41 YA6 YA41 The service user or their representative should sign the care plan to show they have been involved in developing their plan. Care plans should be reviewed at least every six months. A record of each review should be kept with the date. (Care plans were in the process of being reviewed and updated but this was not yet complete.) DS0000028114.V336506.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000028114.V336506.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. 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