Inspection on 01/02/08 for St Helen`s Down

This inspection was carried out on 1st February 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Helen`s Down 30/01/09

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

CARE HOMES FOR OLDER PEOPLE St Helen`s Down 46 St Helen`s Down Hastings East Sussex TN34 2BQ Lead Inspector Caroline Johnson Unannounced Inspection 1st February 2008 10:00 X10015.doc Version 1.40 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 St Helen`s Down DS0000071486.V360032.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 Older People. 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. St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Helen`s Down Address 46 St Helen`s Down Hastings East Sussex TN34 2BQ 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) Evesleigh (East Sussex) Ltd Ms Brenda Elaine Baughurst Care Home 6 Category(ies) of Learning disability over 65 years of age (0) registration, with number of places St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD(E)). The maximum number of service users to be accommodated is 6. Date of last inspection Brief Description of the Service: The registered providers of the service are Evesleigh (East Sussex) Ltd. The property is registered to accommodate six older people with learning disabilities although two of the current residents are under 65 years. In January of this year residents moved from their previous address known as Edmund House. St Helen’s Down is situated in a quiet residential area of Hastings. All resident accommodation is on the ground floor. Three of the six bedrooms on the ground floor have en-suite facilities. Communal areas are generous in terms of space and a large secure decking area has been created in the garden area for use during summer months. A copy of the latest inspection report is on display at the entrance to the home. Fees as of February 2008 range from £1000 to £1175 per week. St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We have assessed that people who use this service receive an adequate quality of care. For the purpose of this report the people living at St Helen’s Down will be referred to as ‘residents’. As part of the inspection process a site visit was carried out on 01/02/08 and lasted from 10:20am until 12:40pm. As there were no residents in the home on that day and the manager was on a course, a second visit was carried out on 13/02/08 and this lasted from 13:45pm until 18:50pm. Over the course of the visits there was an opportunity to meet with all of the residents. In addition time was spent with two staff members in private. All areas of the home were seen. A wide range of records was examined including two care plans and records held in relation to staff recruitment and training, medication, complaints, health and safety, quality assurance and leisure activities. At the time of the last inspection the owners were in agreement that the home known as Edmund House was no longer suitable for the needs of the client group. A new property was purchased and the five residents moved to their new address on 21st January 2008. The new property is known as St Helen’s Down and is registered to accommodate six people with learning disabilities who must be over sixty-five years on admission. Two of the current residents are under sixty-five so some reference will be made to the standards for younger adults. It is acknowledged that following a move extensive work is needed to update all paperwork in order to ensure it is then relevant to the new setting. As part of the inspection process attempts were made to contact the relatives of three residents. However, contact was only achieved with one. One comment received included ‘that the new home is very nice and their relative is settling in well’. They also stated that they were kept well informed by the home of the plans for the move. What the service does well: Staff have regular opportunities to attend staff training and further opportunities are being arranged for more specialist training. Half of the staff team are trained to NVQ level two or above and the home intends that all staff will achieve this level. Staff feel well supported and described the manager as ‘very supportive and approachable’. Residents attend day centres in a variety of settings and the number of days attended is in line with their individual needs and wishes. In addition to the day centres a wide range of activities are provided from the home. Residents St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 6 also said that there is ample time for relaxing in the evenings and at weekends. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents can feel confident that the home is able to meet their needs prior to making a decision about providing accommodation. The service user guide needs to be updated to reflect the new home and to be made available in a more user-friendly format for the benefit of residents. EVIDENCE: At the time of the last inspection the owners were in agreement that the home known as Edmund House was no longer suitable for the needs of the client group. A new property was purchased and the five residents moved to their new address in January 2008. The new property is to be known as St Helen’s Down and is registered to accommodate six people with learning disabilities who must be over sixty-five years on admission. Two of the current residents are under sixty-five so some reference will be made to the standards for younger adults. There is a detailed St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 9 statement of purpose in place, which sets out how the home is to operate. The service user guide has yet to be updated. The manager advised that it is her intention to complete the document in a pictorial format and also to have a taped version of the guide. As part of this process the complaint procedure will also be completed in similar formats. Prior to the move to a new address the placement authority for the residents carried out a review of their individual needs. Residents had been informed about the move at their residents’ meetings. They had one visit to their new home prior to the move. Some of the residents spoken with said that they were a bit anxious prior to the move. They went to their day centre on the day of the move and at the end of the day when they returned to their new home the staff had sorted out their new rooms. Everyone said that they settled in very quickly and were happy that they had moved. A relative spoken with stated that they were advised of the intention to purchase a new property well in advance and that once the date for the move had been finalised they had been informed of this too. There have been no new admissions to the service although the home is currently considering one referral. The manager described their assessment and preparation for admission procedure, which involves the prospective resident having several visits to the service including an over-night stay to ensure that they and current residents are compatible. St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care of residents is promoted because their care plans provide detailed information about their needs and abilities. However, information relevant to the previous home needs to be removed and risk assessments need to reflect the current situation. EVIDENCE: Care plans were examined on the first day of the inspection and discussed with the manager on the second day. It was noted in the two plans seen that some of the information provided related to the previous placement. Some of the risk assessments in place are also no longer required or need to be revised to be applicable to the new placement. A number of the risk assessments had been updated by the time of the second visit. St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 11 In each care plan there is detailed information about the needs of the residents and regular routines are described. There are both guidelines and protocols for staff to follow. The difference between guidelines and protocols were discussed. The protocols read as if they are goals but the advice for achievement is mainly for staff rather than for the resident. The manager advised that it would be better to change the wording to guidelines for both. There are separate goals identified for each resident in another folder and progress with goals is then monitored on a tracker sheet. A daily report folder is also kept which gives a detailed account of each resident’s day. In one care plan there was very detailed information provided about the individual’s visual impairment and how this could affect the resident. In another care plan it was noted that the resident occasionally experiences seizures and there was a protocol written in 2007 advising what to do should the resident experience a seizure. Although it stated that the resident has in the past had a grand mal seizure there was no information to describe a grand mal seizure. Equally on the seizure record chart there is no space to record in detail the type of seizure witnessed. In the daily records there are entries showing that one of the resident’s gets up regularly through the night and wanders around their room. Because of their visual impairment they often have difficulty either finding the door or their bed and often need staff assistance. Staff advised that this was also a problem in their previous placement and that whilst it increased slightly with the move this has settled down again and occurs 3-4 times a night now. There is no risk assessment in place in respect of this. It was reported that keyworkers write a monthly report detailing any changes or updates made to care plans. However these have not been completed since July. The manager advised that the format that was used was not easy to keep up to date and it would be beneficial to revise this to encourage staff to complete this work. Reviews are carried out six monthly and as part of the Regulation 26 visits a care plan is monitored each month. Staff observed in the course of their duties were courteous and friendly and were seem to treat residents with respect and dignity. Medication is stored securely and records seen on the day of inspection were in order. It is the home’s policy that two staff are present when medication is administered. There is a policy on administration of medication. This does not include the use of homely remedies. The manager advised that they currently phone the relevant gp whenever they use a homely remedy or over the counter medication. This medication would not be stored in the medication cupboard. The home’s pharmacy provides training on medication and all staff with the exception of the manager has received recent training on the subject. Records show that residents attend a range of healthcare appointments. When St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 12 necessary specialist appointments are arranged to meet individual needs. In each care plan there is a list of the medications prescribed for the individual, what they have been prescribed for and any know side effects. All but one of the residents was able to keep their GP when they moved home. One resident’s GP said that they now fall out of their catchment area. This resident now has a new GP and attended recently for a review. Arrangements are being made for staff to receive training in the areas of epilepsy awareness, diabetes and visual impairment. One member of staff has attended a course on diabetes. Residents’ views or wishes in the event of dying or death have yet to be assessed. The manager advised that this could be carried out. Arrangements are being made for staff to receive training on the subject. St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have opportunities to participate in interesting and stimulating EVIDENCE: At the time of the last inspection a requirement was made regarding activities for one resident. This person is no longer resident in the home. All of the residents attend a day centre throughout the week. The number of days attended depends on individual needs and circumstances. One resident recently chose to cut down by one day, as five days was getting too much for them. A relative spoken with stated that her sister loves her day centre. One resident takes part in the Special Olympics in a variety of events. Two of the residents have an aromatherapy session every other week. One of the residents spoken with stated that she really enjoys this and finds it very relaxing. One resident has personal development tasks built into their care plan. These include reading, writing and numeracy. St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 14 One resident said that they like to walk to a local shop at the weekends to do some shopping and buy a magazine. Two residents enjoy going to church every Sunday. Some of the residents enjoy board games and playing bingo in the evenings. Some of the residents have family members that visit them periodically or an advocate who is contact as needed. Residents meetings are held monthly. A meeting has been planned for February and minutes were seen of the meeting held in December. There was evidence that a variety of topics were discussed and that each resident was encouraged to speak. At that time some of the residents raised questions about the move and in some cases the response given by staff was documented but not in all cases. Residents spoken with stated that they decide what time they go to bed at and what time they get up. Menus were not examined on this occasion but residents spoken with all stated that they enjoy the food served in the home. One resident said that she enjoys baking cakes. Another said that they talk about menus at their residents’ meetings. St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has good systems in place to ensure that all complaints and any suspicion or allegation of abuse is dealt with appropriately. The updating of the complaint procedure in a user-friendly format will enhance this further. EVIDENCE: There is a detailed complaint procedure in place. As stated previously the home will produce a more user-friendly complaint procedure when they update their service user guide. Records showed that there have been no complaints recorded since 2006. The manager advised that one resident has raised concerns about the move to new accommodation, although their opinion changes periodically. Their social worker has been informed and is due to carry out a review in the coming weeks. Staff spoken with all confirmed that they are supporting this resident to settle into their new environment but there is currently no care plan in place in relation to this. The resident when spoken with advised that they were happy in their new home. Since the last inspection two adult protection alerts have been made to Social Services for possible investigation. In both cases Social Services were happy with the action taken by the home and no further investigation was needed. The manager confirmed that all staff have received training on the subject of adult protection. Staff have not received training on scip but it was reported that arrangements are to be made for this to happen. St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has been designed around meeting the needs of older people and the quality of the work carried out is excellent. A specialist assessment of the building could highlight further environmental adaptations that would be of benefit to those residents with a visual impairment. EVIDENCE: A full tour of the building was carried out. All areas have been decorated to a very good standard. There are six bedrooms on the ground floor, three of which are en-suite. The other three share two adjacent bathrooms. One bathroom has a bath facility and the second has a wet area. Both have toilets and hand basins. Where possible residents were involved in choosing the colour schemes and curtains for their rooms. Bedrooms have been personalised and new shelving has been put up in many rooms. Some of the St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 17 residents have new items of furniture. All of the residents stated that they were happy with their new rooms. Communal areas are in an open-plan style. There is a large lounge, which leads on into the dining area and from this area there is access to the kitchen. From the lounge there are patio doors to the garden. A large area has been decked and this creates a lovely space for residents to spend time in during the summer months. From the decked area there are steps leading into the lawned area. Work has commenced on landscaping this area. One of the residents said that the new house is very spacious compared to the previous house. There is no call system. This was discussed at the time of registration and the owners advised that it was not necessary at this point in time but that they would keep this under review. A relative spoken with described the home as ‘comfortable, warm and quiet’. She advised that her relative is doing well getting to know her way about the home. The manager advised that in order to assist three of the residents who are either blind or partially sighted, they made some environmental adaptations similar to their previous home to assist in mobility around the home. No specialist has assessed the environment in relation to meeting the needs of people with a visual impairment. The laundry has been fitted with an industrial washing and drying machine and there is a COSHH cupboard in this area for storing of all cleaning equipment. All areas of the home seen during the inspection were clean. The majority of the staff team have received training on infection control within the last year. St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are provided with good training opportunities and the plans for further more specialist training will enhance the ability of the staff team to meet the individual needs of the residents accommodated. EVIDENCE: Four staff have left since the last inspection and they have been replaced. The manager advised that she is currently recruiting for two care staff. This is so that the home will be fully staffed for when they have six residents. It should also mean that there would be three care staff on duty at the weekends. Since moving to St Helen’s Down the arrangements for staffing at night have changed. Previously there was a waking and a sleep-in member of staff. The main reason for this was the layout of the building and that it would have necessitated two staff to support residents in the event of a fire. As the accommodation is now all on ground floor level, it is not anticipated that this would be a problem. However, there is an on-call procedure at night so that someone could be called to assist in an emergency. Recruitment records were seen in relation to a member of staff appointed since the last inspection. Appropriate checks had been carried out. This member of staff had been employed for three months but it was noted that there were no St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 19 supervision records. The manager advised that they had met on a regular basis to discuss progress. There is an induction package in place for new staff. The manager confirmed that the company are about to introduce a new induction package that is in line with Skills for Care. A staff-training matrix was supplied which showed that the majority of the staff team are up to date on all mandatory training. It was also confirmed that arrangements are also being made for staff to receive training in the areas of epilepsy awareness, diabetes and visual impairment. A member of staff spoken with confirmed that she had attended a course on diabetes. Three of the six staff have completed NVQ at Level 2 and one of these staff members has also started NVQ Level 3. Another staff member is studying for Level 2 and two more staff will commence studying in the coming months. St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,37,38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The introduction of the health and safety meetings should ensure that the health, safety and welfare of staff and residents remain protected. EVIDENCE: The manager confirmed that she is studying for the Registered Manager’s Award. She stated that during the year she attended a course on employment law and that she, along with another staff member would be attending training on the Mental Capacity Act. St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 21 Minutes were seen of the staff meeting held in December 2007. The manager advised that a meeting had been held a few days prior to the inspection but the minutes had yet to be typed. Two staff spoken with confirmed that they receive regular supervision, which they find very useful. They described the manager as ‘very supportive and approachable’. There was a chart displayed highlighting the supervision dates planned for all staff during 2008. As referred to in the previous section one staff member who has since left employment had not received a formal supervision during their probationary period. It was reported that as part of the quality assurance system satisfaction questionnaires are distributed to relatives and their relatives/representatives. This would have been due in December 2007 but was not carried out due to the move. The manager agreed that it would be a good time now to seek views about the quality of the care provided in the home. A relative spoken with stated that the home is good at keeping in touch. The annual development plan now needs to be updated following the move. Audits are carried out in relation to care plans, health and safety and medication. The manager advised that the company are in the process of reviewing and updating all their policies and procedures. A fire risk assessment was carried out on the building prior to the home opening. Individual fire risk assessments have also been carried out in relation to safety arrangements for each resident. It was noted that the home has yet to carry out a fire drill. As part of the registration process checks were made to ensure that there were certificates in place for gas, electric and portable appliances. The manager also confirmed that a legionella assessment had been carried out. Regular checks are carried out in relation to monitoring of water temperatures. It was reported that health and safety meetings are to be introduced on a monthly basis. An assessment of the building will be carried out prior to this meeting and any issues that need addressing would then be raised. The first meeting was held a few days prior to the inspection and the manager advised that she would draw up a checklist to cover all areas that need to be assessed on a regular basis. Records show that a manager from one of the other services within the company visits the home unannounced on a monthly basis to report on the running of the home. The format in use does not provide space for either the person conducting the visit or for the manager to sign the document. There is also no space to record who was in charge at the time of the visit. St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 2 4 4 4 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 3 2 3 St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 OP1 Regulation 5(1) Requirement The service user guide must be updated to reflect the new home and must be made available in a user-friendly format. All risk assessments currently in place must be reviewed and updated to ensure they are applicable to the home and where there is a perceived risk a new risk assessment must be drawn up. An assessment must be carried out to determine the wishes of the services users in the event of dying and death. An assessment of the building must be carried out by an appropriate specialist to determine if there are any further environmental adaptations that would be of benefit to service users with a visual impairment. Fire drills must be carried out to ensure that all staff and where possible service users are aware of what to do in the event of a fire. Timescale for action 15/04/08 2 OP7 13(4a,c) 31/03/08 3 OP11 12(2) 15/05/08 4 OP22 23(2a,c) 30/04/08 5 OP38 23(4e) 31/03/08 St Helen`s Down DS0000071486.V360032.R01.S.doc Version 5.2 Page 24 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 OP7 OP9 OP37 Good Practice Recommendations Keyworker monthly summaries should be carried out. A homely remedies policy should be drawn up and a list of regular homely remedies/over the counter medications agreed with individual gps for use as and when required. The report format for Regulation 26 visits should allow space to record signatories of the person conducting the visit and the registered manager. 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