Inspection on 14/08/07 for Salisbury Autistic Care Ltd

This inspection was carried out on 14th August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 32 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Salisbury Autistic Care Ltd 07/01/08

Salisbury Autistic Care Ltd 30/05/06

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Salisbury Autistic Care Ltd 28 Holt Road North Wembley Middlesex HA0 3PS Lead Inspector Andreas Schwarz Key Unannounced Inspection 14th August 2007 09:00 Salisbury Autistic Care Ltd DS0000063728.V338076.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 Salisbury Autistic Care Ltd DS0000063728.V338076.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. Salisbury Autistic Care Ltd DS0000063728.V338076.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Salisbury Autistic Care Ltd Address 28 Holt Road North Wembley Middlesex HA0 3PS 020 8908 1760 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) Salisbury Autistic Care Ltd Ms Glenis Mary Castillo Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Salisbury Autistic Care Ltd DS0000063728.V338076.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th May 2006 Brief Description of the Service: Holt Road is a five bedded home in Wembley and trades under the name of Salisbury Autistic Care Ltd. Mrs Glenis Randall manages the home and the Registered Individual is Mr Maynard Harry. The home was registered under the Care Homes Act 2001 in October 2005. The home is specialising in providing care for young adults who are within the autistic spectrum disorder and present some challenges to the service. The building is a detached property on a quite residential street in North Wembley, close to public transport, shops and other amenities. There is a large garden, spacious open plan kitchen and dining room on the ground floor. The home is providing separate rooms for activities, relaxation or cool down times for people using the service. There is off street parking for approximately three cars and unrestricted street parking. The home is providing a people carrier, which can be used for outings; shopping and other activities. The home has currently three vacancies. Fees and charges can be obtained on request from the registered manager. Salisbury Autistic Care Ltd DS0000063728.V338076.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place during August 2007 and lasted eight hours. The registered manager and deputy manager were available during this inspection. People using the service are non-verbal, but I observed staff interacting and supporting them. I spoke to two members of staff the following day over the phone. I viewed a range of documents and records and a full inspection of the premises was undertaken. I would like to take this opportunity thanking everybody involved within the key inspection. What the service does well: What has improved since the last inspection? The home has had one more admission since the last inspection. People using the service have settled and episodes of challenging behaviour have reduced. Salisbury Autistic Care Ltd DS0000063728.V338076.R01.S.doc Version 5.2 Page 6 People using the service finances have been sorted out and the correct benefit is paid to people. The home has met six of the thirteen requirements made during the last key 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. Salisbury Autistic Care Ltd DS0000063728.V338076.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 Salisbury Autistic Care Ltd DS0000063728.V338076.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): People using the service experience a poor outcome in this area. This judgement has been made using available evidence including a visit to this service. The statement of purpose and the resident guide do not give clear relevant information about the home. Applications for admission to the home may be agreed without any reference to a needs assessment. EVIDENCE: I viewed the homes’ service users guide and statement of purpose, which requires more attention and must be updated to meet National Minimum Standards. The registered manager must include information stated in Care Homes Regulations 4, 5 and 6 and a copy of both documents must be send to the Commission for Social Care Inspection once completed. This is to ensure that new prospective people using the service have the appropriate information available about the home. I have viewed both service users folders during this key inspection. One person had a very detailed needs assessment, which was undertaken by the registered manager. The other folder did not contain a needs assessment undertaken by the home; the registered manager informed me that this happened due to the fact that the person was referred as an emergency. I viewed however an assessment undertaken by the person’s previous Salisbury Autistic Care Ltd DS0000063728.V338076.R01.S.doc Version 5.2 Page 9 placement, which had good and detailed information about the persons needs, behaviour, likes and dislikes. I informed the registered manager that needs assessments must be carried out for all people using the service.. Salisbury Autistic Care Ltd DS0000063728.V338076.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): People using the service experience an excellent outcome in this area. This judgement has been made using available evidence including a visit to this service. Staff is committed in supporting individuals to lead purposeful and fulfilling lives as independently as possible. People using the service make their own decisions and have the right to take risks in their daily lives. EVIDENCE: I assessed two care plans during this key inspection; one of the care plans was currently in the process of being completed and was only available on the computer. Both care plans viewed were of very high standard. Care plans are person centred and Autism specific needs such as Triad of Impairment are addressed. People using the service have a communication passport. Staff demonstrated good knowledge of peoples needs and care plan objectives. Care plans have clear guidelines for staff; this ensures consistency in their approaches, which is paramount when supporting people with Autism. Salisbury Autistic Care Ltd DS0000063728.V338076.R01.S.doc Version 5.2 Page 11 The home is recording people using the service likes and dislikes to provide person centred support. Restrictions are clearly documented in guidelines and care plans. The registered manager is acting as an appointee for one of the person living at the home. Financial records were of good standards and the registered manager has supported the person to receive the correct benefits. Behaviour guidelines are in place, which provide reactive and pro-active approaches to challenging behaviours. Risk assessments are detailed and give clear guidelines to staff in how to minimise risk in the community, at home, in the car, etc. The registered manager informed me that risk assessments are reviewed if risks change. Salisbury Autistic Care Ltd DS0000063728.V338076.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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have the opportunity to develop and maintain important personal and family relationships, and are able to access information and specialist guidance about issues such as intimate relationships. People who use services are involved in meaningful daytime activities of their own choice and according to their individual interests and capability. The meals are balanced and nutritional and cater for the varying cultural and dietary needs of the individuals using the service. EVIDENCE: The home is providing and in-house and community based day service. People using the service access activities such as swimming, Jungle Mania, walks in open spaces, music therapy, dance, etc. Due to school holidays some activities have stopped and will recommence again in September. People using the service are involved in light household tasks, which depend on their abilities Salisbury Autistic Care Ltd DS0000063728.V338076.R01.S.doc Version 5.2 Page 13 and mood. The home has introduced a number of new activities since the last inspection and one person has settled in well and enjoys activities offered to him. I viewed excellent records of people’s participation in activities and in the daily logbook. People using the service access the community for activities and outings. The home has some difficulty with a neighbour, which has been addressed and is dealt with by the registered manager and responsible individual. The home has a small minibus, which is used for activities and appointments. The home is encouraging family involvement and one person is ringing his parents regularly. Sexuality is discussed in care plans and Consent visited the home for an assessment of one of the person using the service. Due to the disability and the risk of absconding people using the service currently do not have a key. I observed very good interactions between staff and people using the service, and staff has been available to support people using the service throughout this unannounced key inspection. The home is providing a varied and balanced diet to people using the service. The fridge was well stocked and the home is providing culturally appropriate meals to people using the service. The menu is based on people’s likes and dislikes and individual choices are recorded. The home is recording fridge and freezer temperature. Salisbury Autistic Care Ltd DS0000063728.V338076.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): People using the service experience good outcomes in the area. This judgement has been made using available evidence including a visit to this service. Personal support is responsive to the varied and individual needs and preferences of the people who use services. People who use services have access to healthcare and remedial services; staff makes sure that those residents who are fit and well enough are encouraged to be independent, have regular appointments and visit local health care services. . Medication systems do not always follow good practice or safe practice guidelines. EVIDENCE: I viewed personal care, toileting, bathing guidelines, etc. in people using the service care plan files. All people using the service have been dressed appropriately for the weather and their gender. People using the service mobilise independently and no technical aids are required. During this inspection a behaviour specialist and psychologist visited the home to discuss people’s behavioural issues. The behaviour intervention team from Brent Learning Disabilities Partnership is involved in the home and has provided physical intervention training to staff and behaviour intervention plans for people using the service.. Salisbury Autistic Care Ltd DS0000063728.V338076.R01.S.doc Version 5.2 Page 15 I viewed a health action plan, which was not fully completed. The registered manager informed me that the plan was done together with the community nurse, but the follow up appointment has been cancelled. I recommend rearranging another appointment with the community nurse to complete the Health Action Plan. People using the service are registered with a local General Practitioner surgery. The home is supporting people using the service to access dentist, opticians and other health care services. Previous inspections assessed the medication policy compliant with National Minimum Standards. Medication is stored in a lockable cabinet in the office. The home has a returns book, but I noted that the pharmacist has not signed returns, which is required. Two members of staff administer medication and sign on the Medication Administration Sheet; I suggest devising a separate recording sheet for the second person to sign. Medication Administration Sheet had no gaps. The home is providing in-house medication training. I informed the home that a competent person must provide medication training. I could not find a signatory list in the medication file, which is required. Salisbury Autistic Care Ltd DS0000063728.V338076.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): People using the service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. It is available on request in pictorial form to help anyone living at, or involved with, the service to complain or make suggestions for improvement. Not all staff have received Protection of Vulnerable Adults training to recognise suspected abuse, and people using the service must not pay for breakages if not stipulated clearly in the contract or service users guide. EVIDENCE: The home has a complaints procedure in place, which is compliant with National Minimum Standards. The home has received a number of complaints from neighbours, which have been recorded and dealt with appropriately. The complaints procedure is available in the Service Users Guide. The home has a Protection of Vulnerable Adults policy in place and local adult protection guidelines are available. All but three staff have received Protection of Vulnerable Adults training. I informed the home that all staff must receive Adult Protection training. Staff spoken to demonstrated good knowledge of reporting adult protection allegations. When assessing finances it came to my attention that people using the service are asked to pay for damages, which occurred due to episodes of challenging behaviour. This was not stated in the contract or Service Users Guide issued to the person and the home has no Salisbury Autistic Care Ltd DS0000063728.V338076.R01.S.doc Version 5.2 Page 17 statement informing people using the service of this. I informed the registered manager, That the person must be reimbursed of all monies paid to the organisation in regards to breakages. Salisbury Autistic Care Ltd DS0000063728.V338076.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): People using the service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. The physical environment does not always meet the specialist needs of the people who use the service. The home does not have an on-going maintenance programme in place. Essential maintenance is only done when a problem has already arisen. A number of the fixtures and fittings need replacing and some of the décor requires upgrading. The quality of life for people using the service is being made worse by the environment they are living in. EVIDENCE: The registered manager showed me around the home and I have undertaken a full inspection of the premises. I noted a wide range of damages to the property, which must be repaired to provide a safe and comfortable home for people living there. Room 4 had a number of damages, i.e. broken window, plaster and wall with holes, nails sticking out of the lino and paintwork is damaged, the lid of the toilet cistern was missing. The registered manager informed me that a person using the service, has been moved to a new room.. Salisbury Autistic Care Ltd DS0000063728.V338076.R01.S.doc Version 5.2 Page 19 The light bulb in the landing was missing and the area was very dark, which could lead for people to fall due to poor lighting. The plaster near to the bathroom is exposed and has been covered with Plexiglas. There was a big hole in ceiling of the hallway, which must be repaired. A window handle in room 2 was missing which must be replaced. The missing lamp fitting and hallway must be replaced. Covers of toilet cisterns are missing, which must be replaced. The door handle on the toilet room in the quite room is missing and must be replaced. I left an immediate requirement form and send a serious concern letter to the home; regarding the loose wires above the dining table, which is a risk to people safety. This has now been repaired. The carpet in the kitchen is very worn and must be replaced. The registered manager informed me that dinning chairs and garden furniture have been broken by people using the service, I informed the home that these must be replaced. I found a number of cables hanging loose in the porch, which must be secured. The registered manager informed me that the home has no ongoing maintenance system in place, which is required. The paintwork in the hallway and communal area is very worn and I informed the registered manager that these areas must be redecorated. The laundry room is located on the top floor of the property and people using the service are able to use a washing machine and clothes dryer. The washing machine has a cycle for hot temperature. The home was clean and free of offensive odours during this key inspection. The home has Infection Control procedures in place and cleaning materials were found stored safely. Salisbury Autistic Care Ltd DS0000063728.V338076.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): People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing rotas take into account the needs and routines of the people using the service. The service recognises the importance of training, and tries to delivers a programme that meets any statutory requirements and the National Minimum Standards. The manager is aware that there are some gaps in the training programme and plans to deal with this. The service has a good recruitment procedure that clearly defines the process to be followed. EVIDENCE: Staff spoken to have different skills and experiences of working withy people with Autism. I observed staff who were professional and demonstrated skill when working with people who can challenge the service. The home does not employ staff under the age of 18. Only one of the four assessed files had proof of relevant training in care in care in place. This does not meet National Minimum Standards and it is required to ensure that a minimum of 50 of care staff have relevant qualifications in care. Salisbury Autistic Care Ltd DS0000063728.V338076.R01.S.doc Version 5.2 Page 21 I viewed four staffing files during this inspection; all required recruitment checks were found to be in place. Staff has a training and development plan in place. Staff have attended a number of different training courses such as Health and Safety, First Aid, Food Hygiene, Breakaway, Autism, Challenging Behaviour, etc. I spoke to two members of staff over the phone; both made very positive comments of the support and training received from the registered manager. Staff has received supervisions from the registered manager, but I noted that the minimum requirement of six supervisions per year was not met and discussed this with the registered manager. Staff informed me that the registered manager facilitates regular team-meetings and debriefing sessions after episodes of challenging behaviour. Salisbury Autistic Care Ltd DS0000063728.V338076.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): People using the service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. The Manager has the required experience and is competent to run the home. The manager of the home is not qualified to run a home. People who use the service are not adequately protected or safe in this home. They have little confidence that they will be cared for in a safe way. EVIDENCE: The registered manager is very experienced in care and has been working with people with Autism for a number of years. Staff spoke very positive about the registered manager and told me that she is very supportive and listens to all problems. The registered manager informed me that she and the Deputy Manager have enrolled with a training provider to do the Registered Managers Salisbury Autistic Care Ltd DS0000063728.V338076.R01.S.doc Version 5.2 Page 23 Award. The registered manager and Deputy Manager fund their National Vocational Qualification in Care training and it is strongly recommended that the employer pays this. The registered manager informed me that service users surveys have not been undertaken and no annual development plan is in place. Staff informed me that the last staff meeting was held on 18/07/07 and minutes of this were available for inspection. The registered manager informed me that she is not aware of a business plan and a copy of the business plan was not available for inspection, which is required. I viewed a detailed and up to date fire risk assessment during this inspection. The fire drill log was not up to date and the home must ensure to undertake at least four fire drills per year. Fire points and emergency lights are tested weekly. I could not find clear evidence of regular fire system checks and the registered manager informed me that one was done in December 2006, but a certificate was not available for inspection. I informed the registered manager to forward a copy of the most recent fire system check to the Commission for Social Care Inspection. The Portable Appliances Test Certificate expires on 06/12/07 and the Electrical Installation certificate has expired on 28/04/6 and must be renewed. The home did not have a valid Landlords Gas Safety Certificate and an up to date copy must be forwarded to the Commission for Social Care Inspection. Salisbury Autistic Care Ltd DS0000063728.V338076.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 1 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 1 ENVIRONMENT Standard No Score 24 1 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 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 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 2 X 1 X X 1 X Salisbury Autistic Care Ltd DS0000063728.V338076.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 YA1 Regulation (4)(5)(6) Schedule1 Requirement The home must update the Statement of Purpose and Service Users Guide to ensure new prospective people using the service receive satisfactory information about the home prior to moving in. The home must send a copy of the Statement of Purpose and Service Users Guide to the Commission for Social Care Inspection once updated. The home must ensure that all prospective people using the service have a full needs assessment undertaken by a competent person. The home must ensure that the pharmacist signs medication returned to the pharmacy. The home must ensure to provide a signatory list of staff competent in the administration of medication. The home must ensure that a DS0000063728.V338076.R01.S.doc Timescale for action 01/10/07 2. YA1 (4 & 5)(2) 01/10/07 3. YA2 14(1)(a) 01/09/07 4. YA20 13(2) 01/09/07 5. YA20 13(2) 01/09/07 6. YA20 13(2) 01/10/07 Page 26 Salisbury Autistic Care Ltd Version 5.2 qualified person in the safe administration of medication trains all staff. 7. YA23 13(6) All staff must receive Adult Protection Training. (Timescale of 31/07/06 & 31/03/07 was partially met) 8. YA23 13(6) & The home must reimburse 23(2)(a-d) people using the service of money paid towards repairs due to damages to the property. 23(2)(b) Damp patch in first floor bathroom, bedroom 1 and bedroom 2 must be repaired. (Previous timescale of 15/07/06 & 31/03/07 has not been met) 10. YA24 23(2)(b) Radiator covers throughout the home must be painted. (Previous timescale of 31/03/07 has not been met) 11. YA24 23(2)(d) The broken handle in the kitchen draw must be repaired. (Previous timescale of 15/07/06 & 31/03/07 has not been met) 12. YA24 23(2)(b) The broken fencing in the garden 01/10/07 must be repaired. (Previous timescale of 15/07/06 & 31/03/07 has not been met) 01/10/07 01/10/07 01/09/07 01/10/07 9. YA24 01/10/07 Salisbury Autistic Care Ltd DS0000063728.V338076.R01.S.doc Version 5.2 Page 27 13. YA24 23(2)(d) The damages to Room 4 must be 01/10/07 repaired to ensure a homely and safe environment. All missing toilet cistern lids must be replaced. The missing light bulb in the landing must be replaced. The damaged plasterwork throughout the home must be repaired. The missing window handle in room 2 must be replaced. The missing lamp fitting in the hallway must be replaced. The missing door handle on the toilet door in the quite room must be replaced. The home must ensure that loose electrical wires are safe at all times. The worn carpet in the dinning/kitchen area must be replaced. The loose cable in the porch must be secured to ensure peoples safety. The broken garden and dinning furniture must be replaced. 01/10/07 01/10/07 01/10/07 14. 15. 16. YA24 YA24 YA24 23(2)(c) 23(2)(c) 23(2)(d) 17. 18. 19. YA24 YA24 YA24 23(2)(c) 23(2)(c) 23(2)(d) 01/10/07 01/10/07 01/10/07 20. YA24 13(4)(a-c) 01/09/07 21. YA24 23(2)(d) 01/10/07 22. YA24 13(4)(a-c) 01/09/07 23. 24. YA24 YA24 23(2)(g) 23(2)(d) 01/10/07 The home must ensure that the 01/10/07 home is redecorated to provide a comfortable environment for people using the service. The home must put an ongoing maintenance programme in place to ensure people using the service live and a safe and wellDS0000063728.V338076.R01.S.doc 25. YA24 23(1)(a) 01/09/07 Salisbury Autistic Care Ltd Version 5.2 Page 28 maintained home. 26. YA32 18(1)(a) A minimum of 50 of permanent and agency staff must be trained to National Vocational Qualification in Care Level2 or above. (Previous Timescale of 31/07/06 & 31/03/07 has not been met) 27. YA36 18(2) The registered manager must ensure that all staff receives a minimum of six planned supervisions per year. 01/10/07 01/11/07 28. YA37 9(2)(b)(i) 01/11/07 The manager must ensure to obtain Registered Managers Award and National Vocational Qualification in Care in Care level 4. (Previous Timescale of 31/08/06 & 31/03/07 has not been met) 29. YA39 24 The home must have an annual development plan and a copy of this must be send the Commission for Social Care Inspection. (Previous Timescale of 31/03/07 has not been met) 01/10/07 30. YA39 25(2) The registered provider must forward a copy of the most recent Business Plan to the Commission for Social Care Inspection. The registered manager must forward a copy of the most recent fire system check to the Commission for Social Care DS0000063728.V338076.R01.S.doc 01/10/07 31. YA42 23(4) 01/10/07 Salisbury Autistic Care Ltd Version 5.2 Page 29 Inspection. This is to ensure the welfare and safety of staff and people using the service. 32. YA42 13(4) The registered manager must forward a copy of the Landlords Gas Safety Certificate and Electrical Installation Certificate to the Commission for Social Care Inspection. This is to ensure the welfare and safety of staff and people using the service. 01/10/07 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. 2. 3. Refer to Standard YA19 YA20 YA37 Good Practice Recommendations It is recommended to rearrange the community nurse appointment to complete the Health Action Plans. The home should provide a separate sheet for staff to sign when involved in the administration of medication. It is strongly recommended to provide paid National Vocational Qualification in Care training to managers and care staff. Salisbury Autistic Care Ltd DS0000063728.V338076.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH 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 Salisbury Autistic Care Ltd DS0000063728.V338076.R01.S.doc Version 5.2 Page 31 - 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. 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