Inspection on 27/06/07 for St Michaels

This inspection was carried out on 27th June 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Michaels 17/01/07

St Michaels 06/03/06

St Michaels 18/08/05

St Michaels 02/02/05

St Michaels 19/10/04

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 St Michaels 166 London Road Temple Ewell Dover Kent CT16 3DE Lead Inspector Julie Sumner Key Unannounced Inspection 27th June 2007 10:00 St Michaels DS0000023580.V340310.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 St Michaels DS0000023580.V340310.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. St Michaels DS0000023580.V340310.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Michaels Address 166 London Road Temple Ewell Dover Kent CT16 3DE 01304 823017 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) stmichaels@hqls.org.uk High Quality Lifestyles Limited Mr Duncan Robert Wood Care Home 7 Category(ies) of Learning disability (7) registration, with number of places St Michaels DS0000023580.V340310.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2007 Brief Description of the Service: St Michaels is a home for people with learning disabilities and communication difficulties who present challenging behaviour at times. The home is owned by a private company: High Quality Lifestyles. The companys philosophy is to support people who have displayed behaviour that has caused them and others difficulty and has limited ordinary/usual kinds of life opportunities by positive guidance and a specialised environment. The current fees for the service at the time of the visit range from £1885.00 to £3110.00. Information on the home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address for the home is stmichaels@hqls.org.uk. And for the company is www.hqls.org.uk. St Michaels is registered to provide accommodation for up to 7 people. It is the companys intention for a maximum of 5 people to live in the home in order to provide a high quality level of support to each individual. At present 3 people live in the home. St Michaels is a detached home in the village of Temple Ewell near to the town of Dover. There are basic amenities within walking distance of the home and the town of Dover is approximately 15 minutes drive. There are reasonable public transport links near to the house and there is the facility for service users and staff to use the house car. St Michaels DS0000023580.V340310.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection and the focus was mainly to follow up on issues raised at the previous inspection visit. The inspector visited to talk to the people living in the home, the staff and the registered manager and to view records and practices. The time spent in the home overall was around 5 hours. Information was gathered for this inspection by a variety of means both prior to and during the visits to the home. The CSCI request information from the home routinely and the manager provided all the information requested in the Annual Quality Assurance Assessment (AQAA) prior to the inspection visit. Feedback questionnaires were not sent out at this time due to the short time between the last inspection visit. 4 requirements out of the 8 given at the last inspection visit have been met and 4 remain outstanding. The 3 recommendations are also ongoing. One more requirement has been made at this inspection visit. Since this inspection visit the senior management team and the registered manager have responded by providing evidence of systems and plans in place that were not available on the day. What the service does well: There are good, clear assessments of need for individuals. Two people now have a different kind of written support plan that is designed with their involvement. One person designed his own on the computer. The plans are colourful, have pictures, printed photos, symbols and clear writing to describe what is important to each individual, what they like to do, what they do not like, how they like to be supported, what they want in the future and how they plan to achieve it. This is a more meaningful way of demonstrating each person’s preference in how they wish to be supported with their chosen lifestyle. There are some good positive behaviour support guidelines. The people living in the home are supported to maintain contact with their families. The company has a good staff training programme to reinforce positive behaviour support. St Michaels DS0000023580.V340310.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There is intermittent good practice with regard to supporting people who live in the home with their behaviour and challenging their energy into positive occupation. This is compromised by the lack of proactive management, the state of the building and furniture, the staff changes and the fact that the individuals aggravate each other. The staff need to develop their communication skills to use Makaton in the home. This needs to be included in the homes development plan. Building and refurbishment was underway to improve the home. The home looked shabby in places, there were several areas where repairs and redecoration was needed and furniture was worn out. The manager said he was not fully aware of the building plan prior to the work being started. He had not been able to risk assess and develop a plan of support for the people living in the home whilst the building was ongoing and the support actually provided was reactive. The disruption in the home meant that during the day it is not always safe and the people living there needed to be out. A requirement has been carried over to provide a written maintenance and refurbishment plan. Risk assessments also need to be in place for management of individuals whilst building work is being carried out. The overall range of training in the company is good but there is no structured follow up to check for staff competency and confidence. The high staff turn over is reflective of this. The manager needs to address this in the homes development plan. St Michaels DS0000023580.V340310.R01.S.doc Version 5.2 Page 7 At the last inspection visit a requirement was made to provide additional first aid training following an incident when staff were not sure what to do. This has not been put into place yet. This needs to be added to the staff training plan for the requirement to be met. There is a need to develop a quality assurance system to make sure that how the home is supporting service users and what is happening in the home is fully meeting everyone’s needs and wishes. The requirement made at previous inspections has been carried over again. The building work to improve the access to the home by providing an alternative entrance has been completed but the perimeter fence has not been erected. This was proposed in the fire safety recommendations and remains outstanding. 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 Michaels DS0000023580.V340310.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 St Michaels DS0000023580.V340310.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment process is effective at identifying needs. EVIDENCE: No one has moved in or out since the last inspection visit. Assessments are carried out prior to moving into the home and then reviewed in the home following monitoring of the persons’ wellbeing skill development and behaviour. Recent assessments suggest that whilst individual needs can be identified and met that there are some conflicts between the group living in the home. A meeting has been arranged to consider the options and resolve this. St Michaels DS0000023580.V340310.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 know that their personal goals are reflected in their individual plans. Risk assessments need to be expanded to make sure that the people living in the home are supported when there are changes and to incorporate clear guidelines for staff when managing distressed and aggressive behaviour. EVIDENCE: The staff have continued to design person centred plans with each individual. At the previous inspection visit two had been compiled and were used alongside the service user plan. One of these plans is not yet complete and is currently being worked on by the key worker. This has been more difficult as the person has no speech. None of the written contents were in the home but one of the staff who have been involved talked about how they had established the wishes of the individual and described some of the content. St Michaels DS0000023580.V340310.R01.S.doc Version 5.2 Page 11 The manager explained that the guidelines that are currently contained in the original service user plan will be included. This will then form the main point of reference for support for each individual. There will be an additional service user plan which will contain more detailed guidance and risk assessments. This time the service was not observed to be lead by the people living in the home due the restrictions of the building work that is currently being undertaken. Individual risk assessments define necessary restrictions and interventions that have been agreed by funding representatives. These have been reviewed 6 monthly. There are guidelines for behaviour interventions and the risks need to be highlighted to increase staff awareness. The manager said he plans to review the risk assessments and guidelines as part of the person centred planning process. The two person centred plans that were seen at the last visit are due to be reviewed. The manager explained that some of the goals set by each individual have been reached. St Michaels DS0000023580.V340310.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. More consideration needs to be given to individuals needs when there is disruption in the home that is likely to limit their opportunities. Individuals are supported to maintain contact with members of their families. EVIDENCE: There is some building work being carried out during the day. Two of the people living in the home were out at the time of the inspection visit. One person went to Wolverton Court whist building work was going on but he did not feel comfortable and he came back to his home supported by two staff. There are individual activities plans that are used as a basis for what is offered, although the activities organised for this week are all out of the house to avoid the building disruption. One service user goes to college. All service users have computers. St Michaels DS0000023580.V340310.R01.S.doc Version 5.2 Page 13 Service users require the support of two staff when in the community. The staffing level has been increased to support this and the rota showed that this is consistent. The staff team support individuals to go on holiday if they wish and by a gradual plan. One person has not been on holiday before and there are plans support him. One of the people living in the home has been supported to achieve his personal goals of increasing his contact with his parents. Other parents are involved as before. The manager has stated that he would like to find ways to support the people living in the home with reciprocal friendships. There are no set times for meals as mealtimes are dependent on what activities service users are participating in. Meals are being bought out more at present due to work being carried out in the home. St Michaels DS0000023580.V340310.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 adequate. This judgement has been made using available evidence including a visit to this service. The people living in the home are active and healthy. Staff would benefit from further training to support individuals effectively with communication and health care. EVIDENCE: One person needs support with communication. He has a picture board and a pendant that can be used as a communicator to say to people that he wants to be involved. He is able to use basic Makaton but this is not currently supported and his skills are not being retained or developed. Following advice from the speech and language therapist training was set up for a member of staff to become a Makaton trainer for the team. They attended the course but nothing further has been done to put this into practice. There was a discussed with the manager about introducing some signs into the home maybe at particular times like mealtime and using those signs routinely in the home. Following an event, stated in the previous inspection visit, the staff were unclear about how to respond to an individual’s health need and a medical assessment that should have been made earlier was delayed. Because of the St Michaels DS0000023580.V340310.R01.S.doc Version 5.2 Page 15 level of self-injurious behaviour and high risk to individuals health first aid at work was given as a requirement but this has not been actioned. The manager said that health action plans are to be designed when the person centred plans have been completed. This would probably focus the support needed and indicate the skills staff will need to have to support individuals with minor injuries as well as what to do in an emergency. The manager still needs to check the competency of staff and provide additional training as assessed including more detailed first aid training. The requirement made at the previous inspection, with regard to this, is outstanding. Medication records, storage and guidelines were viewed and discussed with the manager. St Michaels DS0000023580.V340310.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 policies and procedures in the home have been improved to protect service users. Making sure that training is followed up and supported will check that staff have the skills to support individuals in potentially risky or unforeseen situations. EVIDENCE: There is a complaints procedure and this is included in the statement of purpose/service user guide. Staff get to know service users and judge from their responses and behaviour if they are unhappy about something. The registered manager has one-to-one meetings with one person who continues to benefit from having this time to talk through any concerns. The complaints procedure also needs to extend to service users who have communication difficulties. There is a complaints log and there have been no complaints. Staff have attended adult protection training. The manager said that the revised procedure has been discussed with staff in their supervisions. Staff have a 6 monthly refresher for restraint training. The registered manager and other home managers in the company are trained to deliver this training. St Michaels DS0000023580.V340310.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, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Essential maintenance has only been done when a problem has arisen. The ongoing work is going to make improvements to the environment but it is not a pleasant or relaxing place to live at the present. EVIDENCE: The building was in such disrepair that there is a lot of disruption to the home while it is ongoing. The manager said that this is ongoing during the day and the home is made safe during the night. Some improvements have been made to the environment. The leaking roof has been repaired. A dividing wall has been removed making the games room more spacious and lighter. A new carpet has been fitted. The builders were replacing the bathroom floor following an incident where it had been damaged. Part of the kitchen is in the process of being refurbished. The kitchen is showing signs of wear, for example, the cutlery drawer has fallen out. St Michaels DS0000023580.V340310.R01.S.doc Version 5.2 Page 18 The new entrance to the basement has been completed apart from the handrail and it cannot be used until this has been fitted. So is not in use. The lounge that was previously unused has become a favoured place of one of the people who lives in the home. The lounge has comfortable furniture. All the armchairs and settees are worn out apart from in the lounge. The building and furniture does suffer from considerable wear and tear due to some destructive challenging behaviour and there is a programme of replacement and repair but this needs to be reviewed to make sure it is timely to accommodate this. A requirement was made at the previous inspection to provide a written plan of refurbishment and replacement to maintain the home. There was no written maintenance plan in the home for the manager to refer to. Appropriate planning and risk assessment could not be carried out proactively to support the people living in the home while the building and repairs are carried out. The home was not very clean because of all the building work and disruption. St Michaels DS0000023580.V340310.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 adequate. This judgement has been made using available evidence including a visit to this service. Recruitment procedures have improved and there is a good range of training to meet individual needs. Further support and monitoring would benefit staff to make sure that training is put into good practice and that they have the skills and confidence to carry out their role. EVIDENCE: There was a discussion with the manager and staff about staffing levels and their role in the home. One individuals funding has increased and this has enabled the home to continue to have an extra member of staff on shift. Individuals go out 2:1 in the community. This has meant that the home is able to have sufficient staff to cover the outings and activities can occur when individuals want and not on a turn taking basis. In the home on the site visit one person was being supported in the home 2:1. The staff rota was viewed and the middle shift was consistently occupied. Four staff have left employment in the home since the last inspection in January 2007. The shifts are covered by staff working extra hours or staff from other homes in the company. The manager said that unless they use the same agency staff which is not always possible the home is more disruptive with them. Staff under a St Michaels DS0000023580.V340310.R01.S.doc Version 5.2 Page 20 lot of pressure with potential assault and challenging behaviour. Some staff have found this difficult to manage one staff left because they were targeted by one of the people living in the home. Two staff transferred to other homes in the company. The manager needs to consider other strategies to support staff. This should be written into the home development plan. There is an NVQ programme set up. New staff continue from induction and commence training in around 6 months. A sample of staff files were viewed. The focus was on checking the recruitment process for the most recently recruited staff. The files were well organised with evidence of references being taken and an interview procedure. CRBs had been requested for all staff. POVA first checks have been carried out. Earlier in the year there had been some delays with induction training but this had been resolved. Staff spoken to said they had felt well supported in their induction and first few weeks of working. The company training manager is reviewing the induction training to incorporate the common standards but this is not in place yet. Training records were viewed and discussed with staff and the manager. The training is ongoing and courses to maintain health and safety are prioritised. The company has an overall training plan focusing on aspects of positive behaviour support. Adult protection / safeguarding adults training has been organised to make sure all staff have an understanding of their role. Different staff roles have identified training required. The registered manager said that the company training manager was organising the additional first aid training but there had been no progress on this at the time of the site visit. The requirement for first aid training has been carried over. The manager needs to consider ways of checking staff competency and putting training into practice. This should be included in the development plan and staff training plan. St Michaels DS0000023580.V340310.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 adequate. This judgement has been made using available evidence including a visit to this service. There is a clear vision for what the service intends to achieve but this is not managed effectively. It is compromised by the lack of planning and by the lack of basic levels of support for people living in the home of choice, communication and stability in the environment. The quality assurance monitoring is not regarded or implemented as a core management tool. EVIDENCE: The registered manager has over two years experience in management and has completed NVQ 4 in management and care. HQL has designed a training programme for the senior staff to provide them with specialist skills to support St Michaels DS0000023580.V340310.R01.S.doc Version 5.2 Page 22 people who display challenging behaviour. The registered manager has almost finished studying the second year of this course. The company has developed a survey for residents with symbols, which is to be tried out. The registered manager said he intends to do this with one of the more able people living in the home but has not done it yet. The manager also stated that individuals’ behaviour is an indicator of whether the service is meeting their needs. He explained that this is currently an area of debate because he thinks that needs are not being met as well as they could be due to the incompatibility of the group. One person living in the home recently told the manager that he does not like living in the home because of the threats from one of the other people he lives with. The requirement to design and implement a quality assurance monitoring system was first given at the inspection dated 18/08/05 and has been outstanding ever since. Discussed meeting the requirement by producing an audit report of where the home is at now and then providing a development plan. There is some difficulty with the suitability of the building. It had been necessary for various projects to have been undertaken simultaneously causing disruption to the home and lifestyles of the people living in the home. The maintenance team have a plan of building work and repairs that are in the process but a written plan was not available in the home and the registered manager said he had not been involved in the planning. During the visit to the home the bathroom floor was being replaced, following an incident. The new entrance to the basement for staff and visitors has been completed but is awaiting the fitting of a handrail before it can be used. The repairs are all essential and some are urgent but there were no risk assessments available at the time of the visit. The support for people living in the home appeared to be reactive and limited. The requirement to make sure staff have the skills to support individuals in the event of accidents and minor injuries and as part of this to attend the four day first aid training has not been responded to. The registered manager said that one of the company business managers was to arrange first aid training but there had been no progress with this and the registered manager had not followed this up. St Michaels DS0000023580.V340310.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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 2 x x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 2 x 1 x x 1 x St Michaels DS0000023580.V340310.R01.S.doc Version 5.2 Page 24 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 YA19 Regulation 13(4) Requirement Make sure that there are sufficient staff on duty with approved first aid training in line with HSE ratios of staff to service users and having assessed the needs of the service. (Previous timescale of 31/03/07 not met.) There must be a written maintenance plan in the home to include all necessary repairs and refurbishment to the home with proposed timescales. A copy of which should be given to the commission by this timescale. (Previous timescale of 31/03/07 not met.) Timescale for action 30/09/07 2. YA24 23(2)(b) 30/09/07 3. YA39 24(1)(a,b)(2)(3) To set up a quality assurance audit system within the company to measure success in achieving aims and statement of purpose of the home based on views of service users and their DS0000023580.V340310.R01.S.doc 30/09/07 St Michaels Version 5.2 Page 25 4. YA39 5. YA42 representatives. System structure and planned implementation to be completed by timescale. (previous timescale March 2006, 31/05/06 and 31/03/07 not met.) 24(1)(a,b)(2)(3) An audit report needs to be 30/09/07 compiled to demonstrate where the home is now. A development plan needs to be designed to incorporate all areas of improvement needed. 12(1)(a,b) Implement fire safety 30/09/07 23(4)(b) guidance recommendations and ensure safety of service users when evacuating the building in the event of fire.(previous timescale 31/05/06 not met due to delays in building work which is now underway) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA24 Good Practice Recommendations To extend the maintenance and renewal plan to replacement of furniture and equipment to speed up the time it takes to acquire the items requested/needed. To continue to work towards achieving NVQ targets. There are guidelines for behaviour interventions and as part of these the risks need to be highlighted to increase staff awareness. DS0000023580.V340310.R01.S.doc Version 5.2 Page 26 2. 3. YA32 YA9 St Michaels St Michaels DS0000023580.V340310.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 St Michaels DS0000023580.V340310.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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