Inspection on 02/06/06 for St Raphaels

This inspection was carried out on 2nd June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Raphaels 17/10/08

St Raphaels 24/10/06

St Raphaels 24/10/05

St Raphaels 05/04/05

St Raphaels 15/12/04

St Raphaels 14/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 St Raphaels The Butts Brentford Middlesex TW8 8BQ Lead Inspector Mrs Rekha Bhardwa Key Unannounced Inspection 2 and 5th June 2006 09:45 nd St Raphaels DS0000022900.V297615.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 Raphaels DS0000022900.V297615.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 Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Raphaels Address The Butts Brentford Middlesex TW8 8BQ 0208 560 3745 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) The Francis Taylor Foundation Sister Clare Casey Care Home 19 Category(ies) of Learning disability (19) registration, with number of places St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One Service User aged over 65 not by reason of old age Date of last inspection 24th October 2005 Brief Description of the Service: St Raphaels is situated in a quiet residential area in Brentford. It is close to the Brentford High Street and within easy reach of Hounslow and Chiswick town centres. There are good public transport links close by. The home is one of two on the site, managed by the Frances Taylor Foundation. The other home, Maryville, is for older people and is inspected separately. There is also, on the site, a convent and six flats for Sisters of the Order and staff. The large, well maintained gardens are available to all service users within the complex. There is a Roman Catholic church incorporated in Maryville. The establishment is for nineteen service users with learning disabilities and is arranged in three units. Two units are situated over two floors in Fatima House. St Raphaels is a large house, which is detached from Fatima House. St Raphaels has an enclosed courtyard garden. St Raphaels DS0000022900.V297615.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 inspection carried out as part of the regulatory process. A total of 10hours was spent on the inspection process. The Inspector carried out a tour of each house, and inspected service user plans, medication records, staff records, financial records, servicing, maintenance and fire safety records. 10 service users, 5 staff and the Responsible Individual were spoken with as part of the inspection process. It must be noted that some service users have limited communication due to their learning disability. Several requirements have been repeated in this report as they have not been addressed or have been partially addressed. What the service does well: What has improved since the last inspection? What they could do better: St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 6 This inspection highlighted several areas of concern. A number of requirements from the last inspection have not been addressed. Up to date information was not available for a newly admitted service user. Even though there have been some improvements in the area of care planning and risk management further improvements are required. A timescale for the end of August 2006 has been agreed for the full implementation of the new care plan format for all service users. Some shortfalls have been identified with the management of medication. Where service users choose to have their bedroom doors open an appropriate self-closing door mechanism must be fitted. Staffing provision and deployment must be reviewed. Duty rotas must be in place. The management team must undertake team building work with all members of the staff team. Regular staff meetings should take place and the views of staff should be considered. Shortfalls with recruitment and vetting practices have been identified again and this is a repeat finding. A staff training and development programme is required. The systems for the management of health and safety must be improved. 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. St Raphaels DS0000022900.V297615.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 St Raphaels DS0000022900.V297615.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Up to date assessments by the placing authority on the service users needs were not always available and staff do not always have full information of the service users needs. EVIDENCE: One new service user had moved into the home six weeks prior to the inspection. For this service user a Social Services Needs Led Assessment had been undertaken in December 2005. The service user moved into the home in May 2006. A keyworker report and a health action plan were available from the previous placement. A copy of health and social care plan completed by Hounslow Social Services was dated December 2005. It is essential that the home obtain a current Needs Led Assessment from the placing authority and the home has in place up to date information on the service user. This was discussed with the Registered Manager at the time of the inspection. St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Positive steps have been taken in reviewing and streamlining the care plans. Consistency in care planning is required to ensure that service users receive continuity in care. It is essential that when a new service user is admitted to the home that a care plan be formulated within the trial period. Risk assessments must be individual to the service user to ensure that all risks are safely managed. EVIDENCE: Two service user plans were viewed during the course of the inspection. The Deputy Manager stated that all service user care plans had been computerised and the new care plan format had only been recently implemented. Printed copies were available on the files viewed. For one service user who had been at the home for six weeks a service user plan had not been formulated. Copies of care plans from the previous placement were available on the file viewed. The Registered Manager stated that she was still in the process of developing the service user plan for this service user. It was agreed with the Registered St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 10 Manager and the Deputy Manager that all service user plans were to be completed in the new format by the end of August 2006. There was evidence that the completed care plan was being reviewed. Records are kept of service users participation in activities and details of activities of daily living. These are kept in a diary and entries relating to all service users are logged in the diary. The Inspector discussed the need to have an individual record for each service user in keeping with confidentiality and access to records procedures. Service users are encouraged to make decisions about all aspects of their daily lives and within their capabilities. Information and assistance is provided by the staff in supporting service users to make decisions. The Inspector was informed that a local independent advocacy group called Speak out visit the home every Thursday and hold a session titled ‘’speak up’. This is not attended by staff. The home also use the services of Age Concern. The Registered Manager stated that risk assessments were available for all service users. Those viewed were general and several risks had been recorded as one risk. The same outcomes applied to all service users. The method of recording risk assessments must clearly record each individual risk and the control measures in place to minimise the identified risk. This is a repeat finding. Service users also receive training in managing their safety when out alone and using public transport. This is good practice. St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Social and educational opportunities are well managed, supported and provide variety for service users. Meals are provided in accordance with service users choices and preferences. Visiting is encouraged and this enhances the service users lives and keeps them in touch with their families and friends. The meals provided offer both choice and variety to meet the service users preferences. EVIDENCE: A wide range of activities is on offer for all service users living at the home. This included attending day centres, colleges, community activities and one to one activities with staff on duty. The service users who spoke with the Inspector confirmed that they were happy with the arrangements for activities. Evening activities also take place and several of the service users had attended a disco the previous evening. There is a large hall at the home, which is also, St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 12 used by the service users and on the second day of the inspection some dancing and group work had been taking place. Service users are encouraged and supported to use all facilities available in the local community and maintain any individual hobbies. Service users attend evening clubs and other local functions. Information was available in the home about local activities taking place. Service users who spoke with the Inspector were very positive about their social lives. Annual holidays are planned with staff or with relatives. Service users are encouraged to maintain contact with family and friends. Arrangements are place for service users to visit their family or for the family members to visit them at the home. Service users can see their family members and friends in private. The Inspector observed positive interactions between the staff and service users. Staff were observed to knock on service users bedroom doors prior to entering. Service users have unrestricted access to the home and grounds. Fresh food is prepared on a daily basis. Meals are selected with service users on a daily basis. Service users accompany staff to purchase the food and provisions. Where possible staff encourage the service users to participate in meal preparation and meal times are flexible to accommodate service user commitments. Regular weight monitoring is undertaken and the community Dietician is contacted as required. St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The service users health and emotional needs are being well met by the home. The management of medications is adequate and do not always safeguard service users. Shortfalls identified should be easy to address. EVIDENCE: Service users are encouraged to maintain personal care skills. All the service users in the home are female and until recently all the staff were female with the exception of the deputy manger. Daily routines are flexible and accommodate service users needs. Any health and personal support required is detailed in the service user care plan. All service users living in St Raphaels are fully mobile and able to climb the stairs. For those service users who have mobility difficulties they are accommodated on the ground floor in Fatima House. All service users are registered with a General Practitioner. If a service user requires to see the GP an appointment is made for the service user to attend the surgery. Staff accompany service users to all appointments and evidence St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 14 of this was seen on the records viewed. Service users have an annual health check and have access to the Well Women clinic. Service users have access to all primary health care professionals. The Hounslow Community Team for People with Leaning Disabilities also provides ongoing support for service users. The Boots Monitored Dosage System is in place. At the time of the inspection only one service user was able to self medicate. The Registered Manager reported that a risk assessment had been undertaken and that random spot checks also take place. The Medication Administration Records were viewed in each house. These did not record the amount of medication being received into the home. For one service user on Fatima House Risperidone had been prescribed for 22.00hours however the staff had been administering the medication in at 17.30hours, in order that the service user was not agitated for the evening period. It was agreed that the Registered Manager would agree this with the GP and ensure that this was recorded. The Controlled Drugs register viewed was poorly recorded. Entries were made in pencil and full signatures were not always being used. Controlled drugs that were received into the home were not always fully recorded. A medication policy and procedure was available. The Inspector recommended that more information was required in relation to drug errors. Some staff were undertaking the certificate in managing and safe handling of medicines. St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has a satisfactory complaints system in place and concerns are listened to and acted upon. Staff have an understanding of adult protection issues, thus safeguarding service users from abuse. Shortfalls in relation to the recording of service users monies should be easy to address. EVIDENCE: The home has a clear complaints and adult protection procedures. There have been no complaints since the last inspection. One POVA concern was referred to the POVA team in Hounslow. This was investigated and partially substantiated. The Registered Manager stated that all staff working in the home had received training in adult protection by the POVA team in Hounslow. Further training was in the process of being planned on equality and diversity issues. With the exception of two service users all service users have an individual bank account. Small amounts of money are kept for the service users personal items. St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 16 Each service user has an individual record of the money deposited and withdrawn. The records viewed did not have a running place. Service users sign the record when money is deposited or withdrawn. Receipts are kept of any expenditure. St Raphaels DS0000022900.V297615.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The service users are provided with a homely and comfortable environment, which meets their needs and preferences. Shortfalls identified with keeping the bedroom doors wedged open potentially place service users at risk in the event of a fire. EVIDENCE: The Inspector undertook a tour of the premises. The home was found to be well maintained and homely. Plans were in place to have a training room, lift and walk in showers in Fatima House. Fixtures and fittings are of good quality and homely. All service users share the communal garden with another care home. There is a courtyard with garden furniture available. The grounds of the home are well maintained. Individual bedrooms viewed were well maintained, personalised and homely. On the first day of the inspection several bedroom doors on Fatima House were St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 18 wedged open. All these doors are fire doors. On the second day of the inspection all bedroom doors were closed. Where service users choose to keep their bedroom doors open an appropriate self-closing mechanism must be in place. The home was clean and odour free throughout. Service users in St Raphaels are provided with ensuite shower and toilet facilities. Service users in Fatima House have communal bathing and toilet facilities. All bathroom and toilet areas are lockable. Service users choose their own clothes and where they wish to spend their time. Infection control policies and procedures were in place. Laundry facilities are provided on the ground floor of Fatima House and St Raphaels. Both are sited away from food preparation areas. Service users are encouraged to attend to their laundry with staff providing assistance as required by the service user. St Raphaels DS0000022900.V297615.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The staff working in the home were not working together as a team and this effects how the needs of service users are met. The home was not always adequately staffed to meet the needs of the service users. The vetting and recruitment practices were not robust and did not safeguard the service users. EVIDENCE: All care staff working in the care home have completed their NVQ Level 2. The Inspector observed the staff effectively communicating and listening to the service users. The care staff working in the home have a good understanding of the service users needs, and staff have been involved in formulating the care plans. It was not clear on the days of inspection, which staff were on duty and where they were deployed. Planned duty rosters were not in place. The service users in Fatima House have higher dependency needs then those service users St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 20 accommodated in St Raphaels. The Registered Manager explained that all staff work set hours and these hours are the same for each week. The Inspector was not clear how annual leave, sickness and training are planned for. The staff team reflects the gender composition of the service user group. There was little evidence that regular staff meetings take place and there was little evidence of team working. The home does not have a system of staff rotation and staff tended to work in one house only. The Inspector was not clear what autonomy the care staff had and how their views are obtained in the running of the home. No key working system is in place. Staffing provision and deployment must be reviewed and was discussed with the Registered Manager at the time of the inspection. Since the last inspection the Deputy Manager stated that a review all staff files has taken place. Shortfalls had been identified and that the Registered Manager was in the process of obtaining some information which was still required. Two staff employment files were viewed during the course of the inspection. One file viewed had no Criminal Records Bureau check, the Registered Manager stated that a completed application had been sent to the CRB but had not been returned, this file only contained one reference and an incomplete medical declaration. The other file viewed contained no photograph of the staff member. On both application forms the reason for leaving previous employment had not been recorded. These shortfalls are a repeat finding. Some staff training records were available. A training programme for the home is still required. The Inspector recommended that the home develop a training matrix, which would provide the Registered Manager an overview of the training that had been undertaken and what further training was required. Subsequent to the inspection a staff training log was received with the preinspection questionnaire. This detailed the training undertaken but no details were provided of when staff had undertaken the training. St Raphaels DS0000022900.V297615.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 41 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Further improvements are required in the area of quality assurance to develop the self-monitoring of the home. Records required by regulation are not always up to date and this places service users at risk of not having their needs met. Shortfalls in the management of health and safety, potentially place service users at risk. EVIDENCE: A new Deputy Manager had been in post for one month at the time of the inspection. The Registered Manager stated that this appointment had been a positive step for the home. The Registered Manager has a Social Work qualification and has completed the Registered Managers Award. She has been St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 22 the Registered Manager of the home for several years and has substantial experience of working with people with learning disabilities. Results of quality monitoring surveys had not been published. It was not clear what further progress had been made in obtaining the views of staff and significant others. This is a repeat finding. Service user meetings are held and minutes of these meetings were viewed. Systems for the management of records were not always in place. This includes records in relation to service users, staff and the general running of the home. The Registered Managers office had in place records in relation to service users that could be archived. Records required by regulation must be accurate and up to date. Servicing records were viewed at random. Portable Appliance Testing and Fire alarm equipment had been serviced. It was not clear from the records viewed when the Landlords Gas Safety inspection had been undertaken. Legionella testing had last taken place in January 2005. Fire warning tests had been carried out, however the records viewed did not detail which call point had been tested. Fire drills for day staff had taken place, however the records indicated that night staff drills had not taken place. Records of hot water temperature tests were available and had been signed by the member of staff undertaking the test. A diagram of the fire emergency plan was available. No fire risk assessment was available. The Inspector was informed on the second day of the inspection that arrangements had been made for the fire risk assessment to be completed by the fire alarm servicing company on the 6th June 2006. St Raphaels DS0000022900.V297615.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 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 1 35 2 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 2 x 2 2 x St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14 Requirement Where a service user has been referred via care management a copy a recent Needs Led Assessment must be obtained prior to the service users admission to the home. Individual daily records must be maintained in the interests of service user confidentiality. Where a service user is a new admission to the home a service user plan must be in place. Service users plans must be written in sufficient detail to provide clear guidance to staff on actions to be taken to meet service users health and welfare needs. Reviews of service users plans must be recorded to demonstrate any changes and how these are to be met. (Previous timescale of 31/12/05 partially met) Timescale for action 31/07/06 2 YA6 17 31/07/06 3 YA6 4 YA6 15(1)(2)(b) 31/07/06 15(1)(2)(b) 31/07/06 St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 25 5 YA9 13(4)(a)(b)(c) All risk assessments must be tailored and recorded in accordance with service users individual needs. (Previous timescale of 31/12/05 not met) 31/07/06 6 YA18 12(1)(b) Identified goals for 31/07/06 supporting service users with personal care tasks must be more detailed to ensure consistency and continuity of care. (Previous timescales of 31/07/05 and 31/12/05 not Met). The Controlled Drugs Register must be completed in ink and not pencil. Full signatures must be used and the full amount of medication received must be recorded. Dates of opening must be recorded on all liquid medication. A record must be maintained of all medication received into the home. Service users bedroom doors must not be wedged open. Where a service user chooses to have their door open a self-closing door mechanism must be fitted. A staff duty rota must be available. The rotas must demonstrate staff who have actually worked on each shift at any one time. Staffing deployment and provision must be reviewed to meet the needs of the service users. Staff must be enabled to voice their concerns and to 07/07/06 7 YA20 13(2) 8 9 YA20 YA20 13(2) 13(2) 07/07/06 07/07/06 10 YA24 23(4) a 31/07/06 11 YA33 17(2), Schedule 4 (7) 07/07/06 12 YA33 18 31/08/06 13 YA33 12 31/08/06 Page 26 St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 14 YA34 19, Schedule 2 affect the way in which the service is delivered. Work must be undertaken by the management team in the area of team building. Recruitment checks must be carried out as follows: A recent photograph must be obtained of all staff. Evidence of a CRB check must be obtained for one named staff. (Previous timescale of 31/12/05 not met). All information as required by Schedule 2 of the Care Homes Regulations 2001 must be available. 31/07/06 15 YA35 18(1)(a) The staff training 31/07/06 programme must be more detailed indicating the types of training, timescales and staff nominated for the training. (Previous timescales of 31/05/05 and 31/12/05 not Met). Staff training assessments must be devised and implemented. (Previous timescales of 31/05/05 and 31/12/05 not Met). 31/07/06 16 YA35 18(1)(a)(c)(i) 17 YA39 24(1)(a)(b)(2)(3) The outcomes of service users surveys must be published. The home must also seek the views of staff and significant others as part of the quality assurance and monitoring system. (Previous timescales of 31/05/05 and 31/12/05 not Met). 31/08/06 St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 27 18 YA41 17 19 20 YA42 YA42 23(4)(c) 23(4)(e) 21 YA42 12, 13(4) a All records required by regulation for the protection of service users and for the effective running of the business must be maintained, up to date and accurate. Fire alarm tests must record the call point used. All night staff must have fire drill training. Records of this must be available for inspection. Evidence must be provided that current Legionella and gas safety testing has been carried out. The home must have in place a fire risk assessment. This must be available for inspection. 10/07/06 31/08/06 31/07/06 31/07/06 22 YA42 23(4)(c) 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA23 Good Practice Recommendations It is strongly recommended that a running balance of service users money is maintained. St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection 11th Floor West Wing 26-28 Hammersmith Grove Hammersmith London W6 7SE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Raphaels DS0000022900.V297615.R01.S.doc Version 5.2 Page 29 - 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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