Inspection on 24/09/07 for Spion Kop Care Home

This inspection was carried out on 24th September 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Spion Kop Care Home 08/01/09

Spion Kop Care Home 14/01/08

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

CARE HOME ADULTS 18-65 Spion Kop Care Home 72 - 74 Park Lane Pinxton Nottinghamshire NG16 6PS Lead Inspector Bridgette Hill Key Unannounced Inspection 24th September 2007 09:05 Spion Kop Care Home DS0000069743.V343393.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 Spion Kop Care Home DS0000069743.V343393.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. Spion Kop Care Home DS0000069743.V343393.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spion Kop Care Home Address 72 - 74 Park Lane Pinxton Nottinghamshire NG16 6PS 01623 511312 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) Pauline Waddoups Mrs June Thorpe Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places Spion Kop Care Home DS0000069743.V343393.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Mental disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is 4. Date of last inspection Brief Description of the Service: Spion Kop is large converted house situated on the outskirts of Pinxton. It is registered to accept 4 service users aged 18 – 65. The service has chosen to accept only male service users as detailed in the Statement of Purpose. The home is not registered to give nursing care. Service users are accommodated in single bedrooms, one of which has an en suite bathroom. The home is of a domestic style and has a large lounge with a snooker table in it and a separate dining area. The home is not suitable for service users with mobility difficulties as all rooms are on the first floor accessed by stairs. The fees charged at the home are £720 - £750.00 per week, this does not include hairdressing and chiropody. An information pack is made available to each service user in their bedroom. Spion Kop Care Home DS0000069743.V343393.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit which focused on assessing all key standards. As part of the inspection service users care files and a range of documents were examined. A tour of the building was conducted including, with their permission, service users rooms. During the visit opportunity was taken to have discussions with management, staff and service users.. Prior to the visit a form known as an Annual Quality Assurance Assessment was completed by the Manager and returned to the Commission for Social care Inspection. This has been considered as part of this inspection. Service user questionnaires were sent to all service users and staff prior to the inspection as this is a small service. One staff survey was returned during the visit and all service users spoken with during the inspection. As the home has been opened for approximately one month only the standard relating to quality assurance was not formally assessed at this visit. The person in charge at this visit was the Manager June Thorpe. The owner of the home was also present for the majority of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The findings detailed below indicate a wide range of deficits in a number of areas, the service is a new service and there is significant work required to ensure that service users are cared for safely in a home that meets all requirements. The assessment format and the content found recorded on it did not ensure that service users mental health needs and associated risks were assessed. The care plans in place made no reference to service users mental health needs of service users or how these were to be met Spion Kop Care Home DS0000069743.V343393.R01.S.doc Version 5.2 Page 6 The storage of medications was unsatisfactory and did not provide secure storage for medicines. There were not staff on duty for the 24 period who were trained to give medications. There was also some deficits in the recording of medications. There was no provision of activities organised in the home despite care plans referring to encouraging service users to participate in activities. The recruitment process was not ensuring that all required checks were being completed prior to staff starting work at the home. Staff spoken to demonstrated poor knowledge of mental health or related legislation such as the Mental Health Act and the Mental Capacity Act which have a direct impact on the rights of service users. Staff were not sufficiently trained in mental health, Safeguarding Adults There are Health and Safety aspects that place service users at risk of scalds and burns. Water temperatures at bathing outlets and sinks were very hot as were radiators in the home, which had not been risk assessed. 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. Spion Kop Care Home DS0000069743.V343393.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 Spion Kop Care Home DS0000069743.V343393.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,5 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Whilst assessments are undertaken before admission the quality of information is insufficient to ensure service users needs can be met at the home. EVIDENCE: The home has only recently opened and the procedure for admission was examined. This advocated assessment by staff from the home and that service users would be admitted on a 4 week trial basis. There are two service users in the home who had both recently been admitted. The process of admission was discussed with them. All service users had visited the h0ome prior to moving in. Records relating to the admission process were examined. A pre admission assessment format was in place thought his appeared to be oriented towards the needs of the elderly with areas to complete for mobility and tissue viability. The completed forms were found to be poor in recording assessed mental health needs and associated risks. Spion Kop Care Home DS0000069743.V343393.R01.S.doc Version 5.2 Page 9 Some additional information relating to service users was available from previous placements and Care Managers although some of the information available was a few years old. The service is a specialist one which is registered to meet the needs of service users with mental health needs. The assessments and care plans seen, along with discussions with staff indicated that there were significant deficits in the recording of assessed needs and how these were to met. There was no specific training for staff in mental health and no previous experience in some circumstances. Risk assessments in relation to mental health were not fully documented and no care plans were in place for mental health. Discussions were held with the owner regarding service users being informed of the terms and conditions of residing in the home and signing contracts. Information provided was that contracts had been signed by Social Services but service users had not received or signed contracts. Spion Kop Care Home DS0000069743.V343393.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 poor This judgement has been made using available evidence including a visit to this service. The care plans and risk assessments in place were poorly detailed and didn’t include all assessed needs and therefore service users needs may be unmet. EVIDENCE: A sample of 2 care plans were examined at this visit. The care plans viewed contained service users preferred names and photographs of service users. Service users had signed the care plans that were in place. The care plans examined identified needs on some aspects such as hygiene needs, social isolation and sleep. They were poor in describing mental health needs and identifying indicators of worsening mental health. There were no care plans in place relating to medications despite some medications requiring ongoing monitoring and others having some dietary restrictions. The absence Spion Kop Care Home DS0000069743.V343393.R01.S.doc Version 5.2 Page 11 of care plans relating to these issues had the potential to place service users at risk of deteriorating health. Essentially the care plans in place were basic in detailing some needs and had significant deficits in how the service users needs were to be met. There were records completed on a daily basis of how service users had spent their day and of any progress/problems encountered. The home had been open for only a month and no reviews of care plans had yet been completed. In addition to this daily records were kept of hygiene care completed. Whilst the home was not suitable for service users with mobility difficulties Moving and handling risk assessments were seen in care files. Service users spoken with confirmed that routines at the home were flexible and they were able to make choices regarding rising and bedtimes. Some risk assessments were in place for smoking although the room used for smoking did not meet new requirements. No risk assessments were in place in files for some care related needs. This included where there has been identified risks of aggression to staff. The assessment process had not adequately explored the risk assessment profile for service users and therefore no care plans were in place for some documented risks where information had been sought from other healthcare professionals. Spion Kop Care Home DS0000069743.V343393.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 adequate This judgement has been made using available evidence including a visit to this service. The home has yet to develop leisure and social activities, which enable service users to develop interests and ensure service users, were not socially isolated. EVIDENCE: The home has been open for one month and service users spoken to said they had settled in and were happy with the choice of home, mainly as it was quiet. Service users spoke of having the opportunity to go out shopping to local towns and said staff supported them to do this. There were no regular activities offered in the home at this time despite care plans referring to encouraging service users to take part in activities. Social isolation was included in care plans as an identified need for some service users. Service users spoke of being supported to keep in touch and visit friends. Spion Kop Care Home DS0000069743.V343393.R01.S.doc Version 5.2 Page 13 Some life story information had been completed with activities and preferences recorded. Service users undertook some tidying of their bedrooms alongside working alongside staff but generally staff undertook all other domestic duties, laundry and cooking. Service users were observed to ask for drinks which staff made for them. The home does not appear to actively promote independent living skills and did not have assessments in place of service users capabilities or plans of how these could be enhanced. A four weekly menu was available which staff said was not always followed. No records of actual foods served were being recorded. Service users spoken with said they were offered a meal and if they did not like this they could choose something else. Staff spoken to demonstrated they were aware of some of the service users dislikes and stated how these were accommodated. Spion Kop Care Home DS0000069743.V343393.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 poor This judgement has been made using available evidence including a visit to this service. Service users receive good healthcare and professional support from outside of the home. The storage and administration of medicines is poor and staff are not sufficiently trained, this has the potential to adversely affect the care service users receive. EVIDENCE: Staff were observed to knock on service users doors and wait to be invited in before entering. The storage and administration of medicines was examined at this visit. The storage arrangements were found to be inadequate as the type of box being used for some storage had a glass front, another box was also used both were portable and not fixed to the wall. The policies and procedures relating to medications were examined. The administration policy was not available as it was missing from the file. Policies and procedures were general ones which had been purchased and did not wholly reflect the practices in place at the home. Spion Kop Care Home DS0000069743.V343393.R01.S.doc Version 5.2 Page 15 The medication administration records were examined. Some were handwritten without any signatures to verify who had written them. One medication had only the name of a drug recorded without clear dosage, frequency or maximum limits recorded. Records of drugs received in were in place and no drugs had yet needed to be returned. Discussions with staff regarding one topical preparation were held as there were no record of it being given. Staff were unable to say what the medication was prescribed for. There were no care plans in place to record that staff provided support to take medications and no recorded consent/assessment of service users abilities. All service users were registered with a local GP. Additional visits and support were given to service users from Social Workers and a Community Psychiatric Nurse. Staff spoken with said they felt very supported by the Care Managers and Social Workers who visited. Where service users had out patient appointments at hospital staff supported service users to attend these. Records were available to record any visits and appointments. Staff said that service users were not registered with a dentist and that this was their choice but no documents of this decision was recorded. Service users weights were recorded on admission. A form was available to record service users post death wishes. Some of these were complete others were not which was said by staff to be the service users choice. Spion Kop Care Home DS0000069743.V343393.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 poor This judgement has been made using available evidence including a visit to this service. There were not sufficient policies, procedures or staff training in place to ensure allegations and complaints would be handled appropriately. This may adversely affect service users. EVIDENCE: Two complaints procedures were available in the home. These gave different information of the timescales for the resolution of complaints. The home has only recently opened and no complaints have been received at the home or by the Commission for Social care Inspection. The Safeguarding Adults procedure in the home referred to internal investigation as was described by a staff member when they were asked what they would do if any allegations were made. This is not in keeping with locally agreed procedures which is part of the contractual obligations when accepted service users funded by the Local Authority. Some staff had completed Safeguarding Adults training and others had not. This was aid by the Manager to be planned in the next few weeks. Some monies were stored safely on service users behalf. Records of the transactions were recorded and signed by two staff. Where purchases had Spion Kop Care Home DS0000069743.V343393.R01.S.doc Version 5.2 Page 17 been made receipts were available. Service users monies were stored separately and balances of monies did not correlate totally being a few pence out to the actual monies available. Some information was available regarding assessment of service users ability to budget though this was not included as part of the care planned approach to care. Policies and procedures were in place to preclude staff from accepting gifts or benefiting from service users wills. Spion Kop Care Home DS0000069743.V343393.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): 24,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home offers homely accommodation to service users which is clean and comfortable although the smoking area was not suitable to meet new laws and protect non smoking staff and service users from passive smoking. EVIDENCE: The home aims to provide care to service users within a domestic type setting. The home provides a domestic style kitchen and lounge. Laundry facilities are available in a building to the rear of the home and were domestic in style. Service users spoken with staff did their laundry and they were happy with this service. The only lounge in the home was being used as a smoking room. The room had the door open to the dining room throughout the visit and was placing staff at the risk of inhaling smoke from service users cigarettes. Spion Kop Care Home DS0000069743.V343393.R01.S.doc Version 5.2 Page 19 All service users have their own room. One bedroom has an en suite facility with the remaining 3 service users sharing a bathroom with a bath and shower. Service users had some personal possessions in their room and had shown an interest in purchasing items to put in their room. Lockable facilities were available in some bedrooms but not all. A fire alarm is fitted throughout and some emergency lighting is fitted with more said by the manager to be planned. Checks on the fire alarm were documented. Windows upstairs were generally top opening style and were not fitted with restrictors, as they were not unduly large. One window of a lower height was not fitted with a restrictor but was said by staff to be an emergency exit in the event of fire. The fire officer had visited the premises but no report was available. Some fire risk assessments of the home had been completed however a complete fire risk assessment to meet the required regulations was not in place. The home was found to be generally clean and tidy in all areas. Spion Kop Care Home DS0000069743.V343393.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): 32,34,35 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The process for recruiting and training staff was inadequate and did not ensure that staff had the knowledge and skills necessary to ensure service users needs were met. EVIDENCE: The home has only recently opened and there are currently 3 staff including the Manager employed. The Provider of the home is a Registered Nurse and works some shifts at the home. Staff started work at the home on the date service users moved in. The staffing levels on the rota were typically two staff during day shifts and one sleep in staff member at night. Staff had a diverse role which included cooking, cleaning and laundry duties in the home. Job descriptions for staff were available. Service users gave positive opinions of the staff saying they do everything for them. They said staff were available to them if they wanted to talk. Spion Kop Care Home DS0000069743.V343393.R01.S.doc Version 5.2 Page 21 One staff member, the Manager holds a National Vocational Qualification level 2 in care. A sample of 3 staff recruitment files were examined. The files examined had some deficits with staff not completing application forms and therefore no employment histories being recorded. Not all files had two references in place or proofs of identity. All files did have Criminal records Bureau checks in place. The staff training files and induction process were examined. Some staff training had taken place before the home opened, some training had been completed by staff in previous employments. This included fire safety, Moving and handling, challenging behaviour and food safety. One staff member was trained in first aid. Not all staff had received medications training and at night there was not staff on duty who were able to administer medication to service users should it be required. Staff spoken displayed a poor knowledge of legislative aspects relating to mental health such as the Mental Capacity Act and the Mental Health Act and the implications that these could possibly have for service users. There had not been any specific training on mental health for staff, this may adversely affect their assessments and observations of service users as they may be unclear how to approach service users. The induction process was discussed and examined. In one staff file there was a competed induction checklist that was an in house form. A progress format for a skills based induction was available but the full work booklet was not and the Manager was not aware that this was needed. Staff had not received the General Social Care Council Code of Conduct Booklet. Spion Kop Care Home DS0000069743.V343393.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): 37,39,42 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home is not being managed sufficiently to ensure the service is delivered safely and in the best interests of service users. EVIDENCE: The Manager of the home has been formally registered with the Commission for Social care Inspection. The Manager has achieved an National Vocational Qualification level 2 in care but does not currently hold a managerial qualification. The Manager has attended an eight-day managerial course. There appears to be inadequacies in the management of the home in a wide range of areas this includes poor recruitment and training of staff, poor care planning and risk assessing, and potential health and safety issues that affect Spion Kop Care Home DS0000069743.V343393.R01.S.doc Version 5.2 Page 23 service users and staff, these all have the potential to affect the care delivered to service users. The quality assurance processes were not examined at this visit as the home has been open for only a month. No monthly providers visits had yet been completed although a format for recording these was available. A ‘client satisfaction’ survey had been completed by service users shortly after moving to the home and the findings recorded were found to be positive. No formal staff meetings had yet been held and it was said that there was excellent informal communications as there was a small staff team. The home has been registered within the past 6 months and all required service certificates for fixtures and appliances were in place. Some aspects relating to the environment were found to place service users as risk of scalds as water temperatures in bathing outlets and sinks were hot with no recording of temperatures either routinely or at the time service users had baths/showers. Radiators were also very hot to the touch. There was no legionella risk assessment in place to ascertain where risks, if any, where and how these were to be managed. Spion Kop Care Home DS0000069743.V343393.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 x 2 2 3 1 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 1 33 x 34 2 35 1 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 3 x N/A x x 1 x Spion Kop Care Home DS0000069743.V343393.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No – first inspection since registration 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 pre admission assessments must consider the mental health needs of the service user and associated risks to establish if the service users needs can be met at the home The home must demonstrate that staff are trained and conversant with current mental health legislation and have sufficient knowledge in order to assess and meet service users needs Service users must receive terms and conditions contracts which give them required information regarding the home Care plans in place must detail the mental health needs of the service user and how staff are to meet these Risk assessments for service users must be assessed and where evident a plan of care must be developed and implemented to record how this is to be managed Where assistance is given to service users with medication this must be assessed, included DS0000069743.V343393.R01.S.doc Timescale for action 15/10/07 2 YA3 18 30/11/07 3 YA5 5 30/10/07 4 YA6 15 15/10/07 5 YA9 15 30/10/07 6 YA20 13(2) 30/10/07 Spion Kop Care Home Version 5.2 Page 26 7 8 YA20 YA20 13(2) 13(2) 9 YA20 13(2) 10 YA23 13(6) 11 YA24 23(4) 12 YA24 23(5) 13 YA34 19 14 YA35 18 15 YA35 18 16 YA42 13(4) in the plan of care and delivered by staff who have received training and are competent The storage of medicines must be in suitable cabinets which are secured appropriately Medication administration records must clearly detail the drug and all dosage instructions to ensure safe administration Policies and procedures which relate to the practices in the home must be in place to ensure the safe handling and administration of medication The provider must ensure that all staff receive training in safeguarding adults and are conversant in the actions to be taken if allegations are made A fire risk assessment of the premises must be completed and implemented to ensure the safety of staff and visitors The arrangements in place to provide a smoking area for service users must meet all required legislation The provider must ensure staff do not commence employment until all required checks and documentation are satisfactorily in place as detailed in Regulation 19 and Schedule 2 Training must be provided to staff and sufficient records held to demonstrate that staff are sufficiently trained in order to meet service users needs, this relates particularly to mental health needs Staff must undertake a structured skill based induction to ensure they have the skills to meet service users needs The provider must ensure there is recorded monitoring of water temperatures where full body DS0000069743.V343393.R01.S.doc 30/10/07 15/10/07 30/10/07 30/10/07 30/10/07 15/10/07 15/10/07 30/11/07 30/10/07 30/10/07 Spion Kop Care Home Version 5.2 Page 27 17 YA42 13(4) 18 YA42 13(4) immersion is possible and that the temperatures are within 43º or – 2 degrees A legionella risk assessment must be available and identified actions implemented to reduce potential risks to service users A risk assessment for the radiators must be completed and any identified actions taken to ensure service users are not placed at risks of burns 30/11/07 30/10/07 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 YA6 YA23 YA34 Good Practice Recommendations Correction fluid should not be used within care planning or other documents The safe guarding adult procedure should be explicit in describing at what stage there is referral to locally agreed multi agency procedures Staff should be provided with and be conversant with the General Social Care Council Code of Conduct Booklet Spion Kop Care Home DS0000069743.V343393.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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