Inspection on 08/12/06 for Roseleigh

This inspection was carried out on 8th December 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Roseleigh 30/08/07

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Southfields

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

CARE HOME ADULTS 18-65 Roseleigh Roseleigh 39 Ringley Avenue Horley Surrey RH6 7EZ Lead Inspector Deavanand Ramdas Unannounced Inspection 8th December 2006 10:00 Roseleigh DS0000067409.V320262.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 Roseleigh DS0000067409.V320262.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. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roseleigh Address Roseleigh 39 Ringley Avenue Horley Surrey RH6 7EZ 01883 731547 01883 744721 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) Cavendish care Ms Susan Kemp Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection: Not applicable. Brief Description of the Service: Roseleigh is registered with the Commission for Social Care Inspection to provide accommodation and care to six service users with a learning disability. The property is located in Horley in Surrey and close to public amenities and other facilities. Accommodation is on three floors accessed by stairs and comprises of an office, lounge, kitchen, dining area, laundry, bathroom, toilets and six bedrooms with en-suite facilities. The home has a garden which is secure and accessible and private parking is available. The fees charged by the home are £1900 per week. The registered manager is Ms. Sue Kemp. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the homes site visit as part of the key inspection process by the Commission for Social Care Inspection henceforth referred to as the CSCI. The site visit was carried out by Mr. D. Ramdas and commenced at 11:45 hrs and ended at 18:15 hrs and included a tour of the premises, interviews with staff and service users, and a review of documents and records at the home. The inspector noted service users have communication difficulties and judgements were made about them based on their mood, behaviour and information given by staff. The inspector would like to thank the manager, deputy manager, staff, service users, relatives and visiting professionals for their contribution to the inspection. What the service does well: The home has a registered manager who provides management stability, leadership and direction to the staff team. During discussions a member of staff stated ‘‘the manager has an excellent management style, fresh with modern ideas’’ and a relative recorded ‘‘if I have any worries I am confident Roseleigh will try and address them’’. Activities at the home are well planned and organised enabling service users to participate in valued and fulfilling activities. During discussions a member of staff stated ‘‘the quality of care is very good with a range of activities’’ and it is recorded in a service user survey ‘‘I often like to go to the gym and cinema’’. Meals at the home are good and offer variety and choice with healthy eating options. Menu plans have input from a dietician to ensure it is adequate to meet the nutritional needs of service users and during discussions a member of staff with responsibility for food commented ‘‘meals are home cooked with a variety of vegetables’’. The arrangements for healthcare are good with health action plans to promote health. It is recorded by a relative ‘‘I am pleased with care’’ and a member of staff stated ‘‘ recently I went on training to give medications for epilepsy’’. The complaints process is good with complaint information in a widget format (a method of communication using pictures and symbols) to make the information understandable to service users. The inspector noted one complaint recorded about the home with appropriate action taken. The home’s premises are excellent with good quality furniture and fittings and a good standard of décor throughout the home. The provider confirmed planning permission has been obtained to extend the property to provide more space for the enjoyment of service users. It is recorded in a service user survey ‘‘I am happy at the home’’. The home is committed to staff training and development and during discussions a member of staff stated ‘‘there are lots and lots of training and the company pays for it’’ and ‘‘the quality of care is good with guidelines for consistency’’. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 6 The home values equality and staff have value based training to promote privacy, dignity and rights. Further evidence confirmed staff supported service users to participate in community life and person centred plans reflected the unique needs of each individual service user. It is recorded by staff ‘‘we would like service users to become independent both within the group and in the community’’. 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. Roseleigh DS0000067409.V320262.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 Roseleigh DS0000067409.V320262.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for assessing needs must be strengthened to safeguard the welfare of prospective service users. EVIDENCE: The manager stated service users will be admitted to the home following an assessment of needs which will be carried out by the manager or general manager, as appropriate. A review of records confirmed the home had a policy on assessing the needs of prospective service users, an assessment form and proposed care plan including a new admissions checklist. Further evidence indicated the home had assessment information by social services and the homes needs assessment covered personal care, health needs and social support. Following discussions with the manager a requirement has been made for the homes admission procedures to be strengthened to include an assessment and management of risk to safeguard the welfare of prospective service users. During discussions a member of staff stated ‘‘we go out and do assessments and get involved in transition visits’’. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 9 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 adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for care planning need strengthening to reflect the changing needs and personal goals of service users. Decision making at the home must be improved to enable service users to make decisions about their lives with assistance, as needed. The arrangements for risk taking need improving to safeguard the welfare of service users. EVIDENCE: The manager stated service users have individual care plans. A review of records confirmed service users have person centred plans and care plans which sets out in detail action to be taken by staff pertaining to personal care, health needs and social support. Further evidence indicated care plans included management guidelines for service users likely to be aggressive focusing on positive behaviours. The inspector noted person centred plans were not dated and signed by staff and action has been required in respect of this matter to safeguard the welfare of service users. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 10 The deputy manager stated the home had introduced service users’ meetings and records were sampled which included decisions about holidays and Christmas arrangements at the home recorded for action. Further evidence confirmed staff were aware of the disability of service users and provided information in a widget format (a method of communication using pictures and symbols) to support service users to make decisions about their own lives. The inspector noted the minutes of service users’ meetings need to be in a format which is understandable by service users and action has been required in respect of this matter to promote communication and decision making in the home. The home had a policy on risk taking. A review of records in individual care plans confirmed risk assessments covered mobility and domestic tasks to promote the independence of service users with action taken to minimise risks and hazards. The inspector noted a shortfall in risk assessments and a requirement has been made to promote the safety of service users. During discussions a member of staff stated ‘‘the standard of care is good with good guidelines for consistency’’ and a relative commented in a letter to the CSCI ‘‘I am very pleased with care’’. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 11 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. The arrangements for occupation are good ensuring service users participate in valued and fulfilling activities. Community links and social inclusion are good ensuring service users are part of the local community. Relationships are good promoting family links and friendships. The arrangements for daily routines are good ensuring the rights of service users are recognised and respected. Meals at the home are good and offer variety and choice. EVIDENCE: The deputy manager stated service users participated in fulfilling activities. A review of records confirmed service users had a weekly programme of activities and accessed a local college and day centre, supported by staff. Further evidence confirmed the company employed a placement officer to find opportunities for paid and volunteer work for service users. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 12 The home promoted community links and a review of records confirmed service users accessed local shops, clubs, cinema and leisure centres for swimming activities. Further evidence confirmed the home had it’s own transport to promote community access and it is recorded in a service user survey ‘‘I often like to go to the gym or cinema’’. Staff supported service users to maintain family links with family and friends welcomed at the home. A review of records indicated relatives visited the home and service users went home regularly to spend time with family and friends. Further evidence confirmed the home had facilities for service users to see visitors in private with service users having the opportunity to meet people and make new friends at college and social events. The inspector noted service users went to a local football club for a party and to a rugby club for music sessions. The home had a daily routine to promote independence and staff respected the rights of service users. Observations confirmed the deputy manager knocking on doors before entering service users’ bedrooms and staff addressed service users by their preferred names. Further evidence confirmed service users have unrestricted access to the home and staff talked to and interacted with service users and not exclusively with each other. The home had written menu plans and service users participated in planning the menu as appropriate using pictures to make choices about food. A review of menu plans confirmed meals offered variety and choice with healthy eating options. Further evidence indicated menu plans had input from a dietician to ensure it is adequate to meet the nutritional needs of service users and promote health. The inspector noted the home had a named staff with responsibility for menu planning who commented ‘‘meals are home cooked with a variety of vegetables’’. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19&20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for personal support are good ensuring service users receive personal support in the way they prefer and require. The systems in place for healthcare are good ensuring the physical and emotional health needs of service users are met. Medication practice needs strengthening to promote health. EVIDENCE: The home has a policy on privacy, dignity and rights and staff provided flexible personal support outlined in person centred plans. A review of records confirmed service users have written waking and morning routines, and night routines to reflect their personal needs. It is recorded by staff ‘‘we would like service users to become more independent both within the group and in the community’’. Observations confirmed service users had good personal hygiene and were appropriately dressed which reflected flexible personal support by staff. The home had health action plans which described the health needs of service users. Further evidence confirmed service users were registered with a local GP (General Practitioner) and had access to chiropody, dental and optical services, as required. The inspector noted staff had training in epilepsy to meet the Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 14 medical needs of service users and observations confirmed the deputy manager supported a service user to attend an outpatient appointment to promote health. The home had a policy on medications and a service level agreement with a local chemist to supply medications to the home. Further evidence confirmed the home kept a record of medications received by and returned to the chemist to prevent mishandling of medications. A review of records confirmed medication record sheets were dated and signed by staff and the company appointed a named staff with responsibility for medications. Observations indicated the home had adequate storage for medications and the deputy manager had written to the chemist to include homely remedies on medication record sheets to safeguard the welfare of service users. The inspector noted a shortfall in medication practice and following discussions with the deputy manager requirements were made for surplus medications to be returned to the pharmacy and staff to have training in medications to promote health. In addition, recommendations were made for a list of staff names with specimen signatures to be available in the home and handwritten prescriptions to be dated, signed and witnessed by a second member of staff to promote good practice. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. The complaints process is good with complaint information available to staff, service users and relatives. The arrangements for protection need strengthening to safeguard the welfare of service users. EVIDENCE: The home had a complaints policy which was available for information. Further evidence confirmed the policy was in a widget format (a method of communication using pictures and symbols) to make the information accessible to service users. A review of the homes complaint record confirmed one complaint with appropriate management action taken. The inspector noted no complaint was recorded by the CSCI about the home and during discussions a member of staff stated ‘‘I am aware of the complaints policy’’. The deputy manager stated the home had a policy on safeguarding adults and a copy of the local authority (Surrey County Council) procedures on safeguarding adults. Further evidence confirmed the home had a whistle blowing policy and staff are booked to attend training in challenging behaviour to ensure physical and verbal aggression by service users is understood and dealt with appropriately. A review of records confirmed staff needed training in safeguarding adults and action has been required in respect of this matter to protect service users from harm. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 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. 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. The home’s premises are excellent ensuring service users have a comfortable home in which to live. The arrangements for hygiene are good ensuring the home is clean and hygienic for service users. EVIDENCE: The home’s premises are suitable for its stated purpose and in keeping with the local community. On the day of the inspection the home was clean, nicely presented, well ventilated and free from mal odour. Further evidence confirmed the home had good quality furniture and fittings, was bright and comfortable with a very good standard of décor throughout the home. The gardens were secure and accessible and during discussions the provider confirmed planning permission had been obtained to extend the home to increase the size of the dining room for the comfort of service users. A review of records confirmed the home had a fire safety risk assessment dated 27/09/06 and a visit from the local authority (Surrey County Council) Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 17 environmental health department with appropriate action taken. It is recorded in a service user survey ‘‘I am happy at the home’’. The home had a policy on infection control and a service level agreement with an approved contractor for the disposal of clinical waste. Further evidence indicated the home had a laundry room with two washing machines and a dryer with hand washing facilities prominently sited. Observations confirmed staff practiced infection control measures and washed their hands regularly to prevent the spread of infection in the home. Information from the provider confirmed infection control training is planned for staff to ensure the premises are kept clean and hygienic for service users. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34&35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for NVQ need strengthening to ensure service users are supported by competent and qualified staff at all times. Recruitment and vetting practices are good safeguarding the welfare of service users. Training and development is good ensuring service users joint needs are met by appropriately trained staff. EVIDENCE: The manager stated the home is committed to staff training and development and staff have NVQ training. A review of records confirmed the home employed seven full time staff with three staff having completed NVQ training. Further evidence confirmed the company had a contract with an approved provider for the provision of NVQ training and observations indicated staff were approachable by and comfortable with service users. The inspector noted staff have training in autistic spectrum disorders and other relevant and appropriate training to meet the needs of service users. Following discussions a requirement has been made for the manager to do an action plan outlining how the home will meet the NVQ training targets to ensure service users are in safe hands at all times. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 19 The home has a policy on the recruitment and retention of staff with staff recruitment files in good order and stored in a locked cabinet to promote confidentiality. The inspector sampled recruitment files which had completed application forms, written references, CRB (Criminal Record Bureau) disclosure information, statement of terms and conditions and job descriptions. The inspector noted staff have copies of the GSCC (General Social Care Council) code of conduct and discussions confirmed the company is revising staff application forms to include at least a ten year employment history to protect service users from harm. The company had a dedicated budget for staff training and staff have induction and foundation training. A review of records confirmed staff have individual training needs assessment and training is linked to service users’ needs including autism spectrum disorders, epilepsy and challenging behaviour. Further evidence confirmed staff have equal opportunities training and the home valued equality and diversity to enable service users with a learning disability to participate in community life. The inspector noted induction and foundation training needs to reflect Skills for Care common induction standards and a recommendation has been made in this area to promote good practice. During discussions a member of staff stated ‘‘there is lots and lots of training and the company pays for it’’ and ‘‘recently I went on training to give medications for epilepsy’’. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39&42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for day to day management are good ensuring service users benefit from a well run home. The systems for quality assurance need strengthening to ensure service users participate in the review of the home. Health and safety needs strengthening to promote safe working practices. EVIDENCE: The home has a registered manager who has the RMA (Registered Manager Award) qualification and provides management stability, leadership and direction to the staff team. Further evidence confirmed the home had a management structure with clear lines of communication and accountability. During discussions a member of staff stated ‘‘the manager has an excellent management style, fresh with modern ideas’’. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 21 The company has a policy on quality assurance and the provider undertakes regular Regulation 26 (monitoring visits) with appropriate management action taken. Further evidence confirmed the home reviewed and updated policies and procedures at the home and used CSCI questionnaires to obtain feedback about the home. Following discussions with the deputy manager a requirement has been made for an annual review to obtain feedback from service users, family, friends and stakeholders with the results made available to service users and their representatives for information. It is recorded by a relative ‘‘if I have any worries I am confident Roseleigh will try and address them’’. The home has a policy on health and safety and staff have training in health and safety, fire safety and manual handling. Further evidence indicated the home had a policy on COSHH (Control of Substances Hazardous to Health), risk assessments, with products appropriately stored in a locked cupboard for safety. The kitchen appeared clean and hygienic, food was appropriately stored with fridge and freezer temperatures within normal limits. The home had a fire drill on the 28/11/06, fire equipment service inspection on the 22/03/06 and a fire officer visit on the 29/09/06. A review of records confirmed the home did not have a current gas safety certificate and staff needed training in basic food hygiene and first aid. A requirement has been made to address these shortfalls to promote safe working practices. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 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 Standard No Score 1 x 2 2 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 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 2 x 3 x 2 x x 2 x Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 23 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 YA2 Regulation 12(1)(a) Requirement Timescale for action 01/02/07 2 YA6 3 YA7 4 YA9 5 YA20 The registered person must ensure admission procedures include an assessment and management of risk to safeguard the welfare of service users. 12(1)(a) The registered person must ensure person centred plans are dated and signed by staff to reflect the changing needs and personal goals of service users. 12(2)(3) The registered person must ensure information about service users meeting is in a format which is understandable to service users to promote communication and decision making in the home. 13(4)(b)(c) The registered person must ensure risk assessment are dated and signed by staff and the risk assessment pertaining to the epilepsy treatment plan is completed to promote the independence and safety of service users. 12(1)(a) The registered person must ensure surplus medication is returned to the pharmacy to promote health. DS0000067409.V320262.R01.S.doc 20/12/06 20/01/07 20/12/06 15/12/06 Roseleigh Version 5.2 Page 24 6 YA20 13(2) 7 YA20 8 YA23 9 YA32 10 YA39 11 YA42 The registered person must ensure staff have training in medications to safeguard the welfare of service users. 13(2) The registered person must ensure a list of staff names with specimen signatures is available in the home for the safe administration of medications. 13(2) The registered person must ensure staff have training in safeguarding adults to protect service users from harm 18(1)(a) The registered person must do an action plan to outline how the home will meet NVQ training targets to ensure service users are supported by competent and qualified staff at all times. 24(1)(a)(b) The registered person must undertake an annual review of the home to obtain feedback from service users, relatives and stakeholders and the results available for information. 12(1)(a) The registered person must ensure staff have training in basic food hygiene and first aid, and a gas safety certificate is obtained to safeguard the welfare of staff and service users. 01/03/07 10/01/07 10/02/07 20/01/07 01/05/07 01/03/07 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 YA20 Good Practice Recommendations The registered person shall consider ensuring handwritten prescriptions on medication record sheets are dated, signed and witnessed by a second member of staff to promote good practice. The registered person shall consider ensuring the homes DS0000067409.V320262.R01.S.doc Version 5.2 Page 25 2 Roseleigh YA35 staff induction and foundation training programme reflect Skills for Care common induction standards to promote good practice. Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Roseleigh DS0000067409.V320262.R01.S.doc Version 5.2 Page 27 - 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!