Inspection on 25/05/06 for Sandford Road,4

This inspection was carried out on 25th May 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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sandford Road,4 09/07/07

Sandford Road,4 24/10/05

Sandford Road,4 18/04/05

Sandford Road,4 30/12/04

Sandford Road,4 14/09/04

Sandford Road,4 31/01/04

Sandford Road,4 13/05/03

Similar services:

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Herbert Street

Haven (The)

Charis

Hartley House

Brook Drive, 124

Rugby House Project

City Roads Crisis Intervention

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

CARE HOME ADULTS 18-65 Sandford Road,4 4 Sandford Road Bromley Kent BR2 9AW Lead Inspector Miss Rosemary Blenkinsopp Key Unannounced Inspection 25th May 2006 10:00 Sandford Road,4 DS0000006910.V293388.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 Sandford Road,4 DS0000006910.V293388.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. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sandford Road,4 Address 4 Sandford Road Bromley Kent BR2 9AW 020 8313 1017 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) Community Options Limited Mrs Regina Ann Benjamin Care Home 5 Category(ies) of Past or present alcohol dependence (5), Past or registration, with number present drug dependence (5), Mental disorder, of places excluding learning disability or dementia (5) Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Sandford Road is part of the Community Options group of homes. It provides support for five residents in the category of mental disorder including past or present alcohol and drug abuse. The residents in this home are undergoing rehabilitation in order that they may live more independently in the community. The usual length of stay in this facility is two years. Residents in this home are subject to Care Programme Approach (CPA) after care systems. The staff in the home are on site throughout the 24-hour period. The Manager and her deputy support the staff team. Senior management is provided through Community Options and on call systems are in place. Multidisciplinary mental health teams are provided through the Primary Care Trust. All other health care is accessed through the community. The weekly fee for this service is £303.28 per week. The inspection report is available in the home. Staff will, if needed, assist residents to read and understand its content. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted by one inspector over a one day period. It was unannounced. The inspection was facilitated by the Manager. The inspector met with one other staff member and three residents during the visit. The preinspection questionnaire was returned to the CSCI prior to the inspection and comment cards sent out from the information provided. Two residents were case tracked and as part of this inspection. The inspector viewed their care plans, risk assessments and other records related to their stay at Sandford Road. Comment cards were sent to members of the multidisciplinary team and the residents themselves for completion. Two comment cards were received by the CSCI, at the point at which the report was written, one from the GP and the other the Care Manager of one of the residents involved in the case tracking. The Care Manager relayed positive comments regarding the service .The GP had had only limited contact with the service and therefore was unable to answer many of the questions. Generally the support and guidance provided to residents is well addressed in this home, although supporting documentation and record keeping needs more attention . What the service does well: What has improved since the last inspection? The Manager has been in post for some time now and has a stable staff group within the home, although staff sickness has meant the use of bank and agency staff. Consistency is very important for the type of resident within this service, and the home satisfies this where possible. The staff have managed situations satisfactorily and the number of reported incidents to the CSCI under Regulation 37 have reduced. Records relating to medications were reasonably well completed. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 6 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. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 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 Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality rating assessment in this section is poor. This has been based on all of the information provided including the site visit. Residents are provided with opportunities to sample the service prior to any final decision on permanent placement. Assessment information is limited, particularly in respect of specific mental health issues and associated risks, this does not comply with all the elements of Standard 2.2. EVIDENCE: The home offers accommodation and support to mental heath residents in the Borough. There is limited provision for this type of resident and therefore choices in placements are not always possible. Residents do have opportunities to visit the home prior to placement. Where possible overnight stays would be facilitated. Licence agreements are issued to residents once they are admitted. Two residents were case tracked as part of the inspection process, one a longer-term resident, the other a new admission. The information relating to the newest resident included the following records. The pre-admission assessment and supporting information were available. There was a summary of the resident’s past history and an application form. There was evidence that the Manager had assessed the latest admission. The assessment detailed presenting needs, however, more detail was needed in areas such as possible risks and support needed from the multi-disciplinary team. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 9 In the second case notes it was difficult to establish if someone from the home had conducted the assessment although there was some information received from the multi-disciplinary team. Neither of the case notes contained confirmation that, following the assessment, the home was satisfied of their ability to meet the identified needs. Other information, which was difficult to locate included information received under the Care Management Assessment or Care Programme Approach, prior to admission. Summary information in respect of preassessment visits was also unavailable. Please see requirement 1. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9. The quality rating assessment in this section is poor. This has been based on all of the information provided including the site visit. Residents are involved in all aspects of individual goal setting as far as their mental health condition allows. The care plans and associated risk assessments are insufficiently comprehensive in content to adequately address the resident’s needs. Risk assessments need to be robust enough to address and reduce the identified area of risk. EVIDENCE: The care plans of the two residents, who were part of the case tracking, were inspected. Community Options have their own support package which, as stated on previous inspections, is comprehensive and involves the resident. However, the residents who live in this home have limited concentration and mental ability and these documents would be difficult to complete. In those case tracked gaps and blank pages were evident in several areas. Within the files there were a number of different styles and formats to the entries in respect of support and care that the residents needed. There was a CPA care plan, dated 10/01/06, with some problem areas identified and the interventions. However the Community Options support plan was blank. There was separate documentation outlining areas of support. It was difficult to Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 11 extract relevant information from the file or audit trail specific issues. The care plan needed to reflect the resident’s current situation, particularly in respect of her pregnancy and physical health, as this would require specific interventions. More information and detailed interventions needed to be in place to identify relapse, this resident was said to be quite “hormonal “ at the moment, staff indicating a fluctuation in her mood and temperament. Many documents were duplicated. Three areas of risk were identified dated 27/03/06 and due for a three monthly review. This resident was seen to be smoking in her bedroom. There was neither a fire risk assessment in place nor a specific risk assessment regarding her smoking in bed, which is a high risk. The second care plan included the CPA care plan and a review dated 16/02/05. This did not have the name of the author or the resident’s signature. The home must be provided with, and seek to obtain, the most updated reviews and all pertinent information relating to the resident. Risk assessments were in place for a number of issues including fire. These needed reviewing. The support plan was in need of review having last been addressed 26/03/05. Again this support plan was limited particularly in respect of mental health interventions. This resident has had eleven admissions since 1991 and was prone to relapse. There was little to indicate to staff the signs of relapse or the actions to take. Staff themselves were aware of what they needed to do if the resident deteriorated but this was not documented. The inspector met with the one staff member on duty, other than the Manager. He was key worker to one of the resident involved in the case tracking. He demonstrated a good knowledge of the resident he was key worker to. He had a good awareness of his signs of deterioration and relapsing mental health state. He advised the inspector of his family network and supports as well as the leisure activities that he enjoyed. The home does on occasions use agency staff. These staff may not be as familiar with the resident and would need to be furnished with comprehensive information in respect of resident so that they can accurately report anything significant. Please see requirements 2 and 3. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 The quality rating assessment in this section is good. This has been based on all of the information provided including the site visit. It was evident that residents had choice in their day and participated in activities as they wished to do. Involvement with the community and accessing local facilities is an intrinsic part of this and it was evident this occurs. EVIDENCE: Rehabilitation is the focus of residents stay in this home. The stay is usually two years. Residents are expected to participate in all activities of daily living in the home and daily household chores are part of this. Residents do their own budgeting, shopping and cooking with levels of supervision as needed. Healthy eating is promoted although not always adopted by the residents. Each resident has daily household tasks, which they are expected to address. They are also responsible for the maintenance of their own bedrooms, which sometimes causes difficulties when these fall below the acceptable standards. All of these household chores promote rehabilitation skills for more independent living. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 13 Residents are encouraged to access all local amenities including healthcare provision. The home is ideally located for local shopping areas. One resident is particularly interested in plants and he looks after the garden. He cares for the fish as well. Other residents were seen to come and go throughout the inspection, although the two who were case tracked both refused to meet with the inspector. Another resident had a visitor in the home and they went out almost immediately the inspector arrived. In their brief contact with the inspector, the visitor and the resident both expressed satisfaction with the service provided. There is a company newsletter in circulation and it is hoped that residents will start to become more actively involved in the production of this. Residents meetings are held minutes of the last one were seen dated 2/3/06. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 The quality rating assessment in this section is adequate. This has been based on all of the information provided including the site visit. All health care support is accessed through the local community, which for this resident’s age group is appropriate. Specialist services including the multi-disciplinary team provide good support to the home – staff and residents. EVIDENCE: All residents have a responsible psychiatrist and multi-disciplinary input as required. Residents access local GP, dental and hospital services as part of ongoing rehabilitation. In the event that residents attend these appointments unaccompanied then it can be difficult to get accurate information on the outcome. The Manager should endeavour to address this. Within the resident‘s notes it was difficult to establish the level of healthcare that residents accessed. More monitoring of healthcare will need to be in place particularly with the one resident who is pregnant. Medications are stored in the office, a cupboard attached to the wall. There is only one storage area. The CSCI inspecting pharmacist has in the past made recommendations regarding further storage for external preparations. Space is limited and this would be difficult to address, and external preparations are rarely used. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 15 The two residents’ medication charts were inspected. One is currently on no medication, however, she had previously been assessed and had been selfmedicating. Her chart had a clear photograph in place although allergies were not recorded. The second chart contained the resident’s photograph and allergies. Medication was reasonably well documented including records for receipt and returned medications. Only one medication is to be administered for homely remedies purposes, which is paracetamol. The list of those requiring the medication was in place and instructions for maximum dosage. The GP had confirmed this July 2005. In the event that the residents change this should be reviewed. The medication policy was in place dated 2003; this should, as with all policies, have an annual review. Staff in the home undertake medication training and regular proficiency tests. Proficiency tests are undertaken by a senior staff that are external to the home to enable independence and fairness. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The quality rating assessment in this section is good. This has been based on all of the information provided including the site visit. Avenues by which to raise a complaint are available and notified to residents. There is an open culture around complaints, and when raised these are taken seriously. Information in respect of adult protection is in place and available to staff. EVIDENCE: The CSCI has received no complaints regarding this service. Community Options do have their own complaints policy and contained within it are alternative avenues to refer complaints. The inspector’s previous experience with Community Options in this area, is that they take complaints seriously and action appropriately. The home itself has received one complaint, which was resolved through internal avenues. The staff member with whom the inspector met was aware of what constitutes abuse and the action, which should be taken. He was knowledgeable about how to deal with complaints also. It was noted form the training plan 2006/2007 that a video about abuse is about to be purchased; this should not substitute training but complement it. Policies and procedures dealing with abuse were available. In the training file there was evidence of previous adult abuse training sessions for staff. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 17 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): 24,27,30 The quality rating assessment in this section is adequate. This has been based on all of the information provided including the site visit. The home is suitable for the resident group living within it who are generally younger and able bodied. EVIDENCE: Three bedrooms were inspected. Two were to a reasonable standard, the third was very pleasant. The remainder of the bedrooms were locked. The lounge and kitchen areas are maintained in a domestic manner with comfortable seating. The communal areas were satisfactory with the exception on the stair carpet, which was worn and torn in parts. Staining of the carpet was also evident. The ground floor toilet needed descaling and in general a deep clean of high and low surfaces e.g. skirting boards should be considered. Safety features are in place in this home and health and safety checks conducted. The hot water temperatures were satisfactory and window restrictors in place. There are no specific adaptations as the residents in this home are fully mobile. Please see requirement 4. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35 The quality rating assessment in this section is adequate. This has been based on all of the information provided including the site visit. Staff are provided in sufficient numbers be it with the use of bank and agency, who do not offer the same consistency as permanent employees. Staff are provided with sufficient training to adequately equip them with the skills to address the job that they do. EVIDENCE: During the course of the morning, one staff was on duty until the Manager arrived from a meeting. The home was quiet and the Manager has assessed the situation as safe for one member to remain in the home. The staff duty rota indicates that two staff are on duty but in practice this is not always the case as staff assist at another home and the Manager facilitates a group. Staffing levels must be maintained to address all of the residents needs and afford protection to the residents and staff themselves. The staff rota indicated that two staff work throughout the day and one sleeping in at night . Currently there are two staff that are on long term sick hence bank staff are used to meet staffing levels. The home has in place a “lone working staff-risk assessment”, dated April 2005. Again this document should be reviewed when residents and staff abilities within the home change, as was the case. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 19 One staff confirmed that on first starting with Community Options he had received in-house and company induction in 2002. Since then, he had received a lot of training including statutory topics. This staff member is the health and safety officer for the home. He had received a one-day training session on this topic, and had applied for a further course to cover health and safety issues. This extra training should be provided to equip the staff member with sufficient skills to undertake the role. On checking the training file there was confirmation of many training sessions, which he had related to the inspector. Community Options invest a lot into their staff teams including a great emphasis on training. Staff attend the mandatory topics and those specific to residents needs. There is a wide and varied selection of course available to staff both internal and external. Some of the mandatory topics need to be updated on a regular basis; these must be addressed at the correct intervals to include fire and all heath and safety issues. Of the six support staff, three have completed the NVQ level 3. The staff recruitment files will be inspected at Community Options head office later in the year. Please see requirement 5. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,42. The quality rating assessment in this section is adequate. This has been based on all of the information provided including the site visit. The home has a stable staff team and support from the Head Office. An open and inclusive atmosphere prevails throughout the home. Quality insurance systems are in operation, which include staff and residents input. EVIDENCE: The Manager has completed the CSCI registration process for this home. Ms Benjamin has completed the NVQ level 4, in addition to number of other relevant courses. She has been the Manager of this facility for the past year having previously been the deputy. A selection of health and safety certificates were inspected including those for gas and electrical, these were satisfactory. In respect of fire, there were service certificates for the equipment and fire alarms dated January 2006. There were records relating to weekly fire alarm testing and emergency lighting. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 21 The fire risk assessment was dated 28/3/05 this needs to be reviewed. The last fire drill was dated 19/04/06 with one staff member attending as well as some residents. All staff must be sufficiently trained in fire drills, with staff attending two per year. All staff do internal rotation and there are no separate night staff. It is recommended that when fire drills are arranged this includes, where possible, residents. In addition, agency staff and bank staff must be aware of the procedures not only for fire but all health and safety aspects. Quality assurance measures are in place through out the organisation. They include an annual staff survey, the results of which are collated and published. Staff receive supervision and have an annual appraisal. Regulation 26 visits are conducted although the last one on the home’s file was dated 21/04/06 and prior to this 27/09/05. There was a significant gap between the two, and gaps were evident throughout a lot of the reports. The reports were filed but in a muddled fashion. Regulation 26 visits must be conducted monthly unannounced and a report on the findings left. Staff meetings were minuted having taken place approximately every two months. There is a joint staff committee working within Community Options. A Community Options newsletter has been produced and circulated to all homes. It contains information on Company developments and individuals. It is hoped residents will become more active in its production. Please see requirement 6.Please see recommendations 1 and 2. Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 3 X X x 2 X Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 23 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 YA2 Regulation 14 Requirement The Registered Manager must ensure residents are fully assessed and all relevant information obtained prior to admission. Confirmation of the homes ability to meet the assessment needs to be retained. The Registered Manager must ensure that care plans are comprehensive in content, kept under review and accurately reflect all of the residents. The Registered Manager must ensure that contingency plans are in place to detect early onset of relapse and detail the appropriate measures to be put in place to address this. Previous completion date 31/3/05. This is now outstanding. The Registered Manager must ensure that risk assessments are completed in respect of any identified risks to residents. Previous completion date 31/3/05. This is now outstanding. Timescale for action 31/07/06 2 YA6 15 30/09/06 3. YA9 13 30/09/06 Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 24 4 YA26 16 5. YA32 18 The Registered Manager must ensure that all areas are maintained in a satisfactory manner. The Registered Person must ensure that all statutory training is updated for all staff. Previous timeframe for action 30/05/05. This is now outstanding. 30/07/06 30/11/06 6 YA39 26 The Registered Provider must ensure that Regulation 26 visits are conducted monthly unannounced, and a report on the findings available. 30/07/06 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 YA40 Good Practice Recommendations The Registered Person should ensure that all policies are reviewed on a regular preferably annual basis or when good practice or legislation changes. The Registered Manager should ensure all staff sign on receipt of fire training. 2. YA42 Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sandford Road,4 DS0000006910.V293388.R01.S.doc Version 5.1 Page 26 - 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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