CARE HOME ADULTS 18-65
Saeeda Saeeda 17 Green Lane Redruth Cornwall TR15 1JY Lead Inspector
Stephen Baber Key Unannounced Inspection 4th July 2006 09:30 Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Saeeda Address Saeeda 17 Green Lane Redruth Cornwall TR15 1JY 01209 215029 01209 215029 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) Swallowcourt Limited Lynette Horne Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 2nd November 2005 Brief Description of the Service: Saeeda is a care home providing residential accommodation to a maximum of eight adults with a learning disability. The aim of the service is to provide a good quality of care and to support service users to maximise their independence. The company are committed to achieving positive outcomes and the active participation of service users in everything that they wish to do. Service users are supported to maintain contact with their families and to be involved in the local community. The staff team fully understand the needs and aspirations of the service users and support them to achieve their goals. The home is an attractive Victorian property situated close to Redruth town centre. The home is situated within easy reach of the town of Redruth with good access to transport and all the facilities of the town. The company provide free transport for outings. Service users are provided with individual furnished bedrooms and a shared bathrooms and shower rooms. The home is undergoing major upgrading work to all areas throughout the home. At present there is a kitchen on the lower ground floor and dining room and lounge on the ground floor. The company have invested substantially in the recent months to improve the decoration and fabric of the home. The home has a small garden and there is parking for two cars. Service users attend a range of day activities, which are mainly commissioned by the Cornwall County Council Adult Social Care Services Department. Swallowcourt employs a manager and team of staff to provide care and support for the service users living in the home. The managing director and senior manager of the company visit regularly and are available to provide additional specialist input as and when it is required. The ranges of fees are from £325 to £850 per week. Outside work activities to day centres and work placements charges are in addition to the weekly fee. Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Commission are making changes to the regulations and inspection of social care agencies. Inspecting for Better Lives (IBL). We are modernising the way we inspect all social care services and will be more proportionate, more focus on the experience of people using services and focus on providers to ensure quality. This was the key inspection, which took place on 4th July 20065 and lasted for over nine and half hours. The purpose of the inspection was to ensure that service users’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus is on ensuring that service users’ placements in the home result in positive outcomes for them. Unfortunately the registered manager was on sick leave and I was later informed that she would be resigning from her position. Whilst this was disappointing it was decided to go ahead with the inspection. I arrived early in the morning to meet the service users who were preparing to go out at their various day and work placements. The inspection also focused on interviews with service users and their relatives, inspection of records and polices and procedures, safety and employment records and discussion with the deputy manager and the learning disability manager for the company who supported the deputy throughout the inspection. Some of the service users who live at the home have lived there since it was first registered twenty-one years ago. The most recent admission took place one year ago and she said how happy she was living at the home. I contacted service users relatives and I talked with them about the service their relation receives. The feedback was very positive and they stated that they were very satisfied with the care and services provided to their relations at the home. The registered manager returned the pre-inspection questionnaire to the Commission, which provided information to assist the inspection process. The home provides quality outcomes to the service users placed there, which they confirmed during the interviews. The service users stated that they are happy with the staff, are given choices, well cared for and are encouraged to make their private rooms personal. What the service does well:
Service users are not admitted into the home unless they have been assessed to ensure that their needs can be properly met there. The company have
Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 6 introduced an assessment format, which takes into account their health, personal, and social care needs, including their cultural backgrounds. Service users’ assessments form the basis of their written care plans, which set out clearly how their needs will be met. Service users said that they are aware of their care plans during interviews held in the course of the inspection. All of the service users enjoy active lives in and out of the home. Service users have their own rooms and have personalised them. During the week they all attend local day care centres or work placements. There is a lot of activity after work when service users pursue interests of their own choosing. The company provide free transport and take them out to social clubs on two evenings a week and local places of interest at weekends. Service users are planning individual holidays of their choosing and one person took great delight in telling me that she has chosen to go to Brighton this year on her annual holiday. All of the service users said that they are satisfied with the activities provided for them. Service users are encouraged and enabled to maintain contact with their families and friends. They can go out and visit friends in the community if they wish, depending on their skills and confidence levels. Where necessary, the staff supports the service users to achieve their goals. Service users have clear information on their rights and responsibilities in the form of written placement contracts and the home’s service users’ guide. They were particularly complementary of the food and choices provided to them. They are able to help with the shopping and choosing of menus and can have alternatives to the main meal if they wish. Their care plans take into account their nutritional needs and food preferences. The service users currently in the home are able to take care of their personal care needs with appropriate assistance from the staff, in private. Their health care needs are met and they are helped to access a range of local NHS healthcare services to maintain good health. Systems for managing service users’ medicines are safe and ensure that they are adequately protected from medication errors. All staff receive training from the company on the safe handling of medicines. The home has a formal written complaints procedure, which service users are aware of. All of them expressed satisfaction with the care and services provided to them at the home. The company provide training to protect service users from harm and abuse and all the service users said that they feel safe in the home. They are all in contact with people outside of the home that they can turn to for assistance or advice if they wish. The home is currently undergoing a complete redecoration and refurbishment programme. The work carried out so far is to a high standard and improves the overall appearance of the home. Service users all have individual bedrooms with lockable doors. Service users benefit from care provided in a domestic, family-style home, which is kept safe and secure for them. Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 7 What has improved since the last inspection? What they could do better:
All the service users I spoke with stated that they could not think of any changes they would like to make. The inspection identified that reviews of the care plans should take place at least every six months and be updated to reflect the changing needs and agreed changes are recorded and actioned. Also greater evidence should be provided throughout the documentation of the service user participation. Evidence of their agreement with documentation would evidence the homes openness and transparency, which is what everyone is working towards. The registered manager should ensure that risks are regularly reviewed and individually assessed and managed effectively so that they can safely develop their skills, independence and confidence. Staff training and recruitment files should be better presented to make information more easily retrievable and ordered. Updating training should also be put in place. Records of staff training should be clearer, for inspection and planning purposes and to provide full evidence that staff have undergone induction and subsequent training that they need to effectively work with service users. Evidence of equality and diversity and when interviews have taken place should be maintained on individual files. Greater recorded evidence of staff’s awareness with the company’s policies and procedures should be addressed and the company should establish a system of review to enable the staff to have up to date information Further improvements are needed to make the home’s environment more comfortable and homely for service users. Most noticeably, the dining room cupboard, which was untidy with lots of material on it, which could be seen. Consideration should be given to dispensing with the water containers that are
Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 8 used to collect water from the kitchen and taken upstairs to be used to top up the kettle. Formal systems to review the quality of the services (quality assurance) provided by the home should be implemented so that service users and their representatives can be confident that their views and needs underpin the ongoing development of the home. Staff must be aware that they accept legal ownership of all documentation that they write on service users and they must sign their full signatures. 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. Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 9 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 Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 10 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): 2 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service Service users’ needs are assessed before they are admitted to the home so that they can be appropriately met EVIDENCE: There have been no new admissions to the home since the previous inspection. Current service users have written assessments on their personal files, which address their health, social and personal care needs, including needs relating to their cultural backgrounds. The home’s statement of purpose contains information on the admission procedures to the home and confirms that admission is on the basis of assessment of prospective service users’ needs. Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 11 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): 6,7,9. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users have written care plans, which address their needs but reviews should take place to ensure that their current needs are being addressed and actioned. They are assisted to make decisions about their lives and to safely develop their skills and independence. EVIDENCE: Service users have written care plans, based on their assessed needs, which address their health, personal and social care needs, including needs relating to their cultural backgrounds. However there is very little evidence to show that these have been reviewed at least six monthly intervals. In my discussion with the company manager it is the vision of the organisation that it is transparent and open and that all things are shared so that agreement can be reached. Therefore more evidence is required to show that service users sign their agreement to their care plans, are fully involved in reviews and are able to demonstrate their awareness of them during discussions at the time of the inspection.
Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 12 Service users indicated that they are satisfied with the degree to which they are able to make choices during interviews in the course of the inspection. Service users’ individual care plans take account of risks but these should be reviewed. Some service users are able to access the community independently, based on their individual risks and confidence levels. Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 13 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 from evidence gathered both during and before the visit to this service. Service users enjoy active lives in and out of the home. They are assisted to maintain appropriate relationships with their families and friends. They have clear information about their rights and responsibilities. Food is considered to be highly important and meal times considered a social occasion. EVIDENCE: All but one of the service users attend local day centres or places of work during the week. They were all preparing for their various centres at the time of the inspection. During interviews they all expressed satisfaction with the activities provided for them. Service users have access to all parts of the home. All service users have keys to their rooms, which are locked in the daytime. At present the service users are planning where to go on holiday. Holidays can be taken as a group or individual All of the service users are very much part of the local community. Some go out independently and the company also provides free transport for thos
Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 14 people who require support. They regularly go out for meals and shopping with the staff and to local places of interest at weekends. Service users are assisted to maintain contact with their families. They go to social clubs on two nights per week to meet people and socialise. One service user goes out independently to the pub to meet his friends Service users have clear information on their rights and responsibilities through their individual contracts and the home’s service users’ guide. Whilst the service users are involved in all aspects of their daily lives, the records need to reflect this. Service users prepare their own breakfast and are provided with a choice of breakfast cereals and toast during the week with the staff preparing the evening meal. They have lunches at their various centres during the week. They are encouraged to assist with the household shopping. I talked with all the service users and shared a meal with them and they unanimously stated that they like and enjoy the food provided to them. Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 15 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 from evidence gathered both during and before the visit to this service. Service users’ personal and health care needs are fully met. There are safe systems to help them to manage their medication and protect them from medication errors. EVIDENCE: The home’s statement of purpose clearly states that the home is not suitable for people with complex needs and challenging behaviour. I observed the staff appropriately assisting service users to maintain their personal hygiene and personal grooming. A new walk in shower room has been created and was completed to a high standard. Service users’ care plans and daily records consider their physical and emotional healthcare needs. The staff assists service users to access a range of NHS healthcare providers locally. There are records of their visits to GP surgeries, hospitals, chiropodists, dentists and opticians. The staff manages all medication. There were a few gaps on the medication administration sheets (MAR). All staff receives training from the company on
Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 16 the safe handling of medication. The home has purchased a suitable drugs trolley for the administration of medication. Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 17 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 from evidence gathered both during and before the visit to this service. Service users’ views are listened to and acted on and they are protected from abuse, neglect and self-harm. EVIDENCE: There is a clear, written complaints procedure, which has been provided to all the service users in written or verbal form. There are informal house meetings taking place everyday with open and frank discussion taking place. The relatives I spoke with said that the staff interact well with the service users and have always impressed them. Service users have contacts with people outside of the home, to whom they can turn should they feel unable to approach the manager and staff and the company manager visits daily and has an excellent relationship with everybody. Two people have attended multi-agency training on the prevention of abuse of vulnerable adults, run by the local county council. The training will now be cascaded down to all levels of staff. There are clear written procedures to guide staff on the actions they should take should they suspect a service user has been abused, including policies on whistle blowing. Staff are employed on the basis of fair, safe and effective recruitment practices which protects the service users from harm. Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 18 Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The management and staff encourage service users to see the home as their own. It provides a well-maintained environment, safe and comfortable to meet service users needs. There are some areas that require improvement and these have been addressed by the company with a schedule of works planned. EVIDENCE: There has been a significant financial investment by the company since taking over the home two years ago. There is evidence throughout of upgrading work both internally and externally to improve the home. Rooms have been redecorated and refurnished, carpets have been replaced. A copy of the schedule of works planned for the coming months was given to me and this included all areas of the home. Issues like the kitchen on the lower ground floor, unit in the dining room and water containers were discussed with the company manager as areas that should be reviewed as part of the ongoing improvement plan. The home received an inspection from the environmental health officer when it registered and they were satisfied that there are appropriate measures in place to protect service users from cross-infection risks. There is a separate utility room for laundry and equipment is suitable to meet the needs of service users placed at the home. Again the company
Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 20 trainer who works with the home organises training in Infection Control and hygiene practices for staff. Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 21 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): 32,34,35 36. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff roles and responsibilities are clear and they are given access to a range of training courses to enable them to understand the purpose of the home and key values that underpin the standards. Evidence to support fair, safe and effective recruitment and selection of staff in the home has improved but key information is still lacking to fully protect residents from risk. Staff are now better supported and supervised but more evidence should be provided. Training for staff has improved which promotes the quality of the service provided. Individual staff training profiles should be set up to ensure the staff fulfil the aims of the home and meet the changing needs of the service users. EVIDENCE: This is an area that has greatly improved for the staff. The company are proactive in the area of training. The documentary evidence indicates that a range of training opportunities is regularly provided for the staff. The training ranges from mandatory and specialist e.g. fire training, safe handling of medication, First Aid, Basic Food Hygiene, Induction, and NVQ level two and the LADAF course that is designed for people working in learning disability settings. I talked with the staff who stated that they enjoy the training provided by the company and were looking forward to undertaking their National Vocational
Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 22 Training. Staff files were disappointing in that they were not professionally presented and lacked evidence of being linked into supervision, appraisal and an individual training plan. Staffing ratios have been greatly increased by the company and there are two care assistants on duty throughout the day with one sleeping in staff on duty throughout the night. The records regarding the recruitment, selection and vetting of new staff could not be allocated and will be inspected at the next inspection. At the previous inspection not all required key information was in place e.g. Photograph, proof of identification, conditions of engagement and POVA. Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 23 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 from evidence gathered both during and before the visit to this service. The home has very efficient systems to ensure effective safeguarding and management of service users money including records keeping. Service users have access to their records whenever they wish. The service is faultless in its role as agent/ appointee and fulfils all requirements. Service users trust the home implicitly in the handling of their money. EVIDENCE: This was the first management role for the registered manager who has resigned. She was qualified, competent and an experienced nurse. The company were satisfied that she undertook her duties professionally and provided a quality of care to the service users. Service users confirmed that they liked the manager very much and she was always kind. Effective quality assurance and quality monitoring systems based on seeking out the views of service users should be put in place to measure success in achieving the aims, objectives and statement of purpose of the
Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 24 home. The company-training officer produced a training needs graph identifying the ongoing training needs of the staff. This included training in health and safety. Reviews of risk assessments should also take place to ensure that service users are safe from harm. The areas of risk should cover environmental, personal and adequate systems in place to protect service users from the risks of fire and cross infection. The company provide infection control, fire, basic first aid and food hygiene training to all staff. There are safe storage facilities for medicines and hazardous systems. The home is secure and service users confirmed that they feel safe there. Staff at all times should ensure that the back door is locked. On the occasions I have visited the home I have got in to the main body of the house undetected. In the managers absence contact should be made with the head of maintenance to bring the fire plan as required by the fire authority up to date and clarification regarding the testing of all electrical appliances and recording should be sought from him and all detail as laid out in standard 42(3). Further staff awareness of the current policies and procedures should be established in a more professional way rather that signing the back of the page. The equipment and services provided to the home are regularly serviced and monitored and satisfactory fire arrangements are in place Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 25 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 X 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 X 34 x 35 3 36 2 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 2 X 2 X X 2 x Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 26 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. 2. Standard YA36 YA39 Regulation 18(2) 24 Requirement Timescale for action 07/01/07 All staff must have regular, recorded supervision meetings at least six times a year. Quality assurance exercise must 07/01/07 be carried out to ascertain the service users views, review and development of the home 2Nd notification RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5.
Saeeda Refer to Standard YA6 YA9 YA20 YA24 YA35 Good Practice Recommendations Care plans should be reviewed and updated and shared with service users or their representatives. Risk assessments should be updated to reflect the service users care plan and of the homes risk assessment and risk management strategies. All persons who dispense medication to the service users should sign the MAR sheet. Arrangements should be put in place to address the carrying of water from the kitchen and to make the dining room look better presented. Individual staff training plans should be established and
DS0000058449.V292701.R01.S.doc Version 5.1 Page 27 6 YA42 ensure staff fulfil the aims of the home and meet the changing needs of service users and staff files should be more professionally presented. The fire plan, risk assessments back door and staff awareness of the policies and procedures as detailed in standard 42 should all be addressed by the company Saeeda DS0000058449.V292701.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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