Inspection on 09/01/07 for Shrewsbury House

This inspection was carried out on 9th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shrewsbury House 07/01/08

Shrewsbury House 12/01/06

Shrewsbury House 23/06/05

Shrewsbury House 25/01/05

Shrewsbury House 10/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Shrewsbury House Shrewsbury House Battlebridge Lane Merstham Surrey RH1 3LT Lead Inspector Lisa Johnson Unannounced Inspection 9th January 2007 09:15 Shrewsbury House DS0000013789.V325444.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 Shrewsbury House DS0000013789.V325444.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. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shrewsbury House Address Shrewsbury House Battlebridge Lane Merstham Surrey RH1 3LT 01737 215135 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) Ashcroft Care Services Ltd Alan Joseph Bitsios Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18-65 YEARS 12th January 2006 Date of last inspection Brief Description of the Service: Shrewsbury House is a five bed roomed detached residence located in Merstham village. Three bedrooms are situated on the ground floor within close proximity to bathroom and toilet facilities. Communal areas on the ground floor include a spacious television room, a well-equipped kitchen and combined dining area. Separate utility facilities are situated in the conservatory. Upstairs there are a further two bedrooms, a second bathroom with separate shower and an office. Accommodation is domestic in scale and character. Local shops and community facilities are within walking distance of the home. Redhill town is accessible by public transport and provides a larger shopping centre and leisure amenities. The weekly fee ranges from £ 982- £1,734. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The site visit was unannounced and took place over seven and half hours commencing at nine fifteen and finishing at five o’clock. The visit was carried out by Mrs. L Johnson Regulation Inspector The inspector spoke to five service users to gain their views on the care provided. These comments are reflected in this report. A full tour of the premises took place. Information was examined which was provided by the registered manager in the pre- inspection questionnaire. Staff training records, staff files and policies and procedures were sampled. The inspector spoke to four members of staff. The inspector would like to thank the staff and service users for their time, assistance and hospitality during this inspection. What the service does well: The home provides a welcoming and friendly atmosphere. Staff were observed supporting service users make choices and decisions. During this visit two service users chose to get up later in the morning and their preference for this was respected by staff. During this visit the inspector spoke to all service users who live in the home. They spoke positively about the care and support they receive and comments included; “I am allowed to go in the kitchen when I want to and make drinks”. “The staff respect my choice when I want to spend time on my own in my room”. “I like living in this home very much”. One individual described the staff as “caring” and another individual said, “the staff are very nice”. Service users are supported to access a range of activities and interests, which meet their needs and preferences. One person keeps birds and fish and told the inspector “I like visiting the pet shop and going to car boot sales”. Another individual said, “ I go to college”. All service users had received holidays with one service user stating, “I went to Greece with my key worker”. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 6 The inspector spoke to the key workers for two individuals who had a good knowledge of the care needs of the service users they support and were clear about their roles and responsibilities. What has improved since the last inspection? What they could do better: Three individual care plans were sampled. Two Individuals goal plans must be updated and recorded to reflect any agreed changes discussed at service user care review meetings to ensure that all identified needs are met. It was recommended that the registered manager consider implementing person – centred care plans. Individual risk plans were in place. It was evident that plans including selfmedication risk assessment for two individuals had not been recently reviewed and updated. A requirement was made that this matter is completed to ensure that the health, welfare and safety of service users is protected. During this visit four staff personal files were examined. One individual had only one written reference available. It was required that a second reference is obtained and that staff must not commence employment in the home until the recruitment checks have been undertaken to ensure that the health, safety and welfare is protected by the homes recruitment policies and practices. During this visit the staff personal files maintained in the home could not be accessed due to the unavailability of the registered manager. It is recommended that the company implement a system to ensure that such records are available for inspection. During inspection of the health and safety records sampled relating to food storage. A requirement was made that this matter be addressed to ensure the health and well being of service users. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 7 It was recommended that the company provide a report on the outcomes of the quality assurance questionnaires, in order to demonstrate that areas identified for improvement by service users and others are addressed. During a tour of the premises it was evident that radiator covers were not provided to protect the health, welfare and safety of service users. Therefore a requirement was made that a risk assessment is completed to review the need to install these in the home. 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. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with information they need to make an informed choice about the suitability of the home as a place to live. The needs of service users are assessed prior to admission to the home. EVIDENCE: The home provides a Statement of Purpose and service user guide, which are produced in a format to allow them to be read by service users. The inspector was informed that these are issued to service users. One service user spoken to confirmed that he had seen a copy of this document. Copies were observed on individual’s files and were signed by service users where possible. There have been no new admissions in the home for two years. During this visit three-service user files were examined. The registered manager was not available during this visit and this information had been archived in other files within the home that were not accessible for viewing. A number of assessments were available on working files, which indicated that a number of regular assessments have been conducted and updated. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with an individual care plan, which records their individual needs and goals although improvement is needed to ensure that goals plans are updated to reflect any changes in need. Service users are supported to make decisions about their lives with assistance and are supported to take risks as part of an independent lifestyle. EVIDENCE: During this visit three individual care plans were sampled. Each service user has a care plan based on a detailed full needs assessment which address health, personal, emotional and social needs. It was evident that plans are reviewed annually, six monthly and monthly with records maintained. The individual goal plans for two service users had not been updated to reflect any changes or outcomes from reviews. A requirement was made that this matter is completed to ensure that individual plans accurately reflect the current and changing needs of service users. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 11 It was recommended that the home consider implementing a more service user-friendly format such as person centred care plans to make them more accessible to service users. During this visit the inspector spoke to two members of staff who act as key workers. They had a good knowledge and awareness of the individual needs of the service users they support and are involved in their reviews. Individuals signed plans and risk assessments where they were able. The home has a key worker system in place. The inspector spoke with four service users who knew who their key workers were and confirmed that they are supported to make decisions. Three service users told the inspector that they are invited to attend their individual meetings. One individual showed the inspector the tea making facilities that he had acquired for his bedroom. During this visit one individual told staff that he felt tired and staff respected this individuals wish not to attend his activities on that day. Two service users were observed to be having a lie in bed respecting their choice. Three service users told the inspector “I can go to the kitchen when I want to make drinks”. Another individual stated “ Staff let me spend time on my own in my room when I wish to”. Choices made by service users and how these can be supported were documented in assessments. One member of staff spoken to said that prospectus has been obtained to assist a service user in choosing their preferred classes at college. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a range of appropriate activities and engage in a range of leisure activities. Service uses are supported to take part in the local community. The rights and responsibilities of service users are respected. The home is able to demonstrate that service users are provided with a wellbalanced and nutritious diet. EVIDENCE: The home provides a range of recreational and leisure activities for service users to attend. It was clear that activities were tailored to suit individual needs and preferences. Records were sampled for three service users. Activities attended for example included gardening with the outreach project, attending day services, going shopping, and pub trips, bowling and during the visit a reflexologist attended the home. One individual told the inspector “I go to college”. Three Service users spoken with said that they had been away on holiday with one individual confirming, “I went to Greece with my key worker”. Daily notes Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 13 were sampled for three service users, which indicated that activities recorded in the plan, were taking place. Service users are supported to participate in household activities and one individual said, “I help to cook the dinner”. Another individual said, “I have help to clean my room”. Service users have a range of interests and hobbies. One service keeps budgies and fish in his room and told the inspector “I like visit the pet shop and going to car boot sales”. Another individual likes to read and the quiet room had a collection of books and reading materials. All service users were observed to have TVs, videos and music equipment in their rooms. Service users are supported to maintain links with their family and friends and one individual said he goes home to see his family. Another individual said he been to visit his friend. A telephone is available for service users to access to maintain links with their family and friends. During this visit staff were interacting with service users who were observed to be relaxed and comfortable in their presence Service users were able to access all areas of the home with no restrictions and are provided with a key if they choose to have one. Two individuals spoken to choose not to use a key. The inspector was informed by staff that service users have access to their own post. One Individual told the inspector “I like spending time on my own in my room when I want to”. Copies of the homes menus were supplied with the pre- inspection documentation and were observed to be varied and well balanced. Choices are accommodated and are indicated on the menu. Service users spoken to during this visit told the inspector that each person takes it in turns weekly to have their own favourite meals on the menu. All service uses spoke positively about the meals provided. Service users going out to daily activities ere supported to make their sandwiches for lunch. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that service users receive personal support in the way they prefer. Service users physical and health needs are met. One matter needs attention to ensure that service users are protected by the homes medication administration procedures. EVIDENCE: During this visit it was observed that the wishes of individuals and their preferences regarding the times they get up was respected. The inspector was informed that if service users had a preference regarding the gender of staff providing support that this would be accommodated. Three plans were sampled which indicated that service users have access to a range of health care specialists including for example a General Practitioner, chiropodist, dentist, dietician and optician. Primary health care checklists were in place for all service users, which were well maintained and accurately, recorded confirming when appointments have taken place and when next appointments are due. One individual told the inspector he is supported by staff with his weight reducing diet. Weight records were maintained and this Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 15 individual’s key worker was aware of their needs and confirmed that this service user has access to a dietician. Policies and procedures medication administration were in place. A list was maintained for all staff that are trained and authorized to administer medication and it was reported that staff undertake an annual assessment. All medications had been signed for following administration. The cupboard was examined and found to be in good order. Records were in place for all medication received and disposed of. Medication is dispensed in blister packs and dispensed from a local chemist. The inspector was informed that the pharmacist visits occasionally to carry out an audit. A consent form was seen and signed by one individual confirming agreement for staff to administer him medication. One individual self medicates and has a suitable lockable cupboard in his bedroom. A risk assessment had been completed but must be reviewed and updated to ensure that service users are protected by the homes medication policies and practices. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that the views of service users are listened to and acted upon. Service usersd are protected from abuse. EVIDENCE: There is a complaints procedure in place. No complaints have been received since the previous visit. Three service users spoken to were asked if they knew whom they could speak to if they were unhappy and responses received included my “ key worker”, “the manager” and outside contacts for example the behaviour specialist. Service users spoken to during this visit spoke positively about the home and the care they receive. Comments included, “I like living here very much”, “the staff are caring”. “the staff are nice”, “It’s a very nice house and staff help me”. The local authority safeguarding adult abuse policies and procedures were in place. The company has its own policy, which was also seen on display in the home. Four staff responded appropriately to a scenario discussed with them as to their actions if they ever witnessed any abuse taking place. Four staff spoken to have completed safeguarding adults from abuse training and this was confirmed by training records examined. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a well-maintained, clean, comfortable, homely and safe environment. The home is able to demonstrate that service users bedrooms promote their independence EVIDENCE: A tour of the premises was completed during this visit. Communal areas were well maintained and appropriately furnished. There is a conservatory to the rear of the house, which leads to the garden. A separate quiet room is available which contained a range of reading materials. One person has mobility difficulties and access to a bedroom and bathroom on the ground floor has been accommodated to meet this individuals needs. Bedrooms were viewed as comfortable and were personalised with individual’s preferences and hobbies. Separate laundry facilities were available. The home was cleaned to a good Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 18 standard and was clean and hygienic with cleaning schedules in place and hand-washing facilities were available. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment practices protected the service users, although a minor gap was identified for improvement. Appropriately trained staff meet the needs of service users and they are aware of their roles and responsibilities. EVIDENCE: The registered manager supplied copies of the staff duty rota, which indicated that there are sufficient staff to meet the needs of service users. There is three staff on during the day. At nighttime there is one waking and one sleep in member of staff. During this visit there was a senior care worker who was acting as shift leader and two other care workers. There has been low staff turnover and limited use of agency staff. The registered manager was unavailable for this inspection and the inspector was unable to access staff files. However arrangements were made to visit the company’s office to view staff files. During this visit four members of staff were interviewed which indicated that they have received mandatory training including safeguarding adults from abuse, health and safety, fire, food hygiene, first aid and manual handling. Two members of staff had completed training in autism, challenging behaviour and non- violent crisis intervention Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 20 training, which meets the needs of the current service users. This was confirmed by the records and certificates maintained at the companies head quarters. The company maintains computerised records and records how often these courses should be updated. The shift leader told the inspector he was completing a National Vocational Qualification (level 4) in care. The deputy manager had completed National Vocational Qualification (level 3) and two members of staff working in the home had completed National Vocational Qualifications (level 2.) The inspector had the opportunity to speak to the company’s training manager who told the inspector that arrangements were in place for other staff to complete the National Vocational Qualifications. New staff receive induction based on the Learning Disability Award Framework (LDAF) standards. One member of staff spoken to confirmed to the inspector that she had completed the induction package and workbook. Records and documents were examined for four members of staff at the company’s head office. Police checks were completed. Three out of four files examined contained two written references, however only one reference was in place for one individual. Therefore a requirement was made that this matter is completed to ensure that service users are protected by the recruitment policies and procedures. It was recommended that the company implement a system to ensure that such records are available for inspection. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is able to demonstrate that service users benefit from a home, which is well run and in the best interest of service users. The health safety and welfare of service users is mainly protected with two issues needing attention. EVIDENCE: The registered manager was unavailable during this visit. However information received indicated that the manager is completing the Registered Managers Award and training records conveyed that the manager has completed a range of training and development. Four staff spoken to stated that, “The manager is approachable, “supportive” and “there is good team work”. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 22 The service holds service user meetings and notes were examined. It was stated that the company is currently updating quality assurance questionnaires, which are being conducted with all service users. A relatives survey has been completed. It is recommended that the company provide a copy of the outcomes of the survey. The registered provider conducts monthly quality monitoring visits. Documents sampled indicate` that these are detailed including interviews and consultation with service users. The homes fire record book was examined which indicated that regular alarm checks, fire evacuations and equipment checks are completed. Records were sampled for water temperature testing which were regularly checked and recorded. Accident records and incidents records were sampled for three service users. Records were appropriately maintained with two incidents being recorded. Pre- inspection information indicated that all routine maintenance and checks were completed and up to date. A requirement was made that a risk assessment is completed in respect of the need to install radiator covers, as these had not been provided. The manager is advised to address this to ensure` the health, welfare and safety of service users. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 23 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 3 2 X 3 3 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 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 24 No 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 YA6 Regulation 15(2)(b) Requirement The registered person must ensure that the individual goal plans are kept up to date to reflect the current and changing needs of service users identified through care plan reviews. The registered person must ensure that individual risk plans are reviewed and updated to ensure the health, safety and welfare of service users. The registered person must ensure that the risk assessments for service users who self medicate are reviewed and updated as required to ensure the health and safety of service users. The registered person must ensure that no staff are employed in the home until all recruitment checks are completed including two written references. The registered person must ensure after consultation with the environmental DS0000013789.V325444.R01.S.doc Timescale for action 09/02/07 2. YA9 13 (4) (b)(c) 09/02/07 3 YA20 13 (2) 23/01/07 3. YA34 19 (1-5) Schedule 2 09/02/07 4. YA42 16 (2) (j) 09/02/07 Shrewsbury House Version 5.2 Page 25 health agency make suitable arrangements regarding food hygiene practices in the home. 5 YA42 13 (4)(c) A risk assessment must be completed in respect of the need to install radiator covers throughout the home to ensure that unnecessary risks to the health and safety of service users are identified and as far as possible eliminated. 09/02/07 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 YA6 YA34 YA39 Good Practice Recommendations It is recommended that the registered person consider implementing person – care plans. It is recommended that the arrangements for accessing staff personnel files in the absence of the registered manager be reviewed. It is recommended that the outcomes of the quality assurance questionnaires be documented and included in the homes development plan. Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shrewsbury House DS0000013789.V325444.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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