Inspection on 20/09/06 for Stanmore House

This inspection was carried out on 20th September 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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 Sudbury Care Homes 12 Binyon Crescent 12 Binyon Crescent Stanmore Middlesex HA7 3NF Lead Inspector Dia Balraj Key Unannounced Inspection 20th September 2006 & 5 October 2006 09:00 Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.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 Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.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. Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sudbury Care Homes 12 Binyon Crescent Address 12 Binyon Crescent Stanmore Middlesex HA7 3NF TBC 020 8922 7873 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) Mr Kevin Tyahooa Mr Kevin Tyahooa Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 2006 Brief Description of the Service: Stanmore House is a residential home providing personal care and accommodation for 3 people with learning disabilities. At the time of this inspection only two service users were being accommodated at the home. The provider and registered manager is Mr Kevin Tyahooa. The home aims to provide a normative life for the service users and enable them to enjoy all the facilities and amenities available within the community. The home is situated in a quiet residential area of Stanmore and is close to public transport and shops. The ground floor accommodation consists of a lounge, dining room, kitchen, one bedroom with en suite and one toilet. The second reception room has a patio, which opens on to an enclosed garden. The first floor accommodation consists of 2 single bedrooms 1staff bedroom, bathrooms and toilets. Some of the residents are supported to attend local day services and the home also provides day care in house. The home has its own transport that enables the residents to access the wider community. Please contact the provider for information about fee levels. Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on Wednesday 20th September in the morning. None of the service users were present during the early part of the inspection. The home currently accommodates two service users and the registered person was in the process of filling in the existing vacancy. The inspector spent 7 hours at the home and was able to meet one service user in the afternoon on his return from the day centre. The registered person/manager was interviewed regarding the operation of the home and viewed policies and procedures and relevant documentation. The inspector also interviewed the deputy manager. The inspector interviewed the service user when he returned from the Day Centre. The inspector did not meet the second service user on this inspection. A second visit was convened on Thursday 5th October when the Inspector was able to interview the second service user and the staff on duty. The inspector was able to gauge the standard of care by obtaining feedback from both service users as well as staff and by observing the interaction between staff and service users. Prior to this inspection a random visit was carried out on 11th July 2006 following a complaint from a service user. The purpose of the visit was to check on appropriate procedures and practices in respect of complaints, abuseprevention, and challenging behaviour management (standards 22 and 23). This followed an allegation of abuse in the home that was being considered under Harrow’s Protection of Vulnerable Adults Procedure. The complaint was investigated and found to be unsubstantiated. This inspection additionally checked progress relating to the requirements made on the inspection of the 11th July. What the service does well: What has improved since the last inspection? Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.R01.S.doc Version 5.2 Page 6 The inspector noted that the following requirements from the last inspection had been carried out. Risk assessment for challenging behaviour Behaviour charts implemented with involvement of all professionals 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. Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.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 Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.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 was good. This judgement has been made using evidence available on the site visit. A thorough assessment of prospective residents’ needs is carried out to determine whether their needs can be met. EVIDENCE: The inspector obtained evidence from documentation, from observation and from discussion with the manager. The documentation of the last admission was examined and included a Care Management assessment plan. There was also evidence of care assessments by the Manager. The latter contained information on Physical health and nutrition, social and emotional support, medication, managing finances, intellectual skills and development, personal care, mobility and transfers, intervention to manage risk and safety, communication and challenging behaviour. The manager stated that the resident concerned had undertaken two visits to the home with a relative and had chosen his room. The resident was introduced to other resident and interaction was observed to gauge the suitability of the placement. Additional visits were made by the social care worker and the prospective resident. The care plans examined identified residents’ needs and the required action to achieve objectives. Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.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): 6,7,9 Quality in this outcome area was good overall. This judgement has been made using evidence available on the site visit. Service users’ needs are identified and they are enabled to make choices. They are encouraged to develop independent skills. ` EVIDENCE: The evidence under this section was obtained from documentation, interviews with manager and staff and interview with service users. The individual care plans of both service users were viewed. These contained information on individual needs and how needs will be met. The service users are able to care for themselves but need prompting and support. Risk assessments identified restrictions on choice. These included use of the washing machine, support in the kitchen, going out in the community, use of the gas hob. Following a requirement from the last inspection there is regular input from the day service in completing the behavioural chart.. Risk assessments had also been updated to include behaviours recorded in the incident book. The home is now working in conjunction with the Day centre in addressing behavioural issues. The manager stated that guidelines in behaviour modification had been received from the Psychiatrist. It is required that there are clear guidelines about the use of Behavioural modification techniques. Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.R01.S.doc Version 5.2 Page 10 There must be records of the explanations given to the service user and the service user’s consent to the use of the technique. There must also be a record of approval by the manager prior to the use of the technique and of each instance when it is used. The technique must be reviewed regularly to monitor whether it continues to be of benefit to the service user. There was clear indication from speaking to service users that they were enabled to make choices. One service user stated that he chose what he wanted to wear and eat. Both service users have a programme of activities during the day and evenings. They attend activities and classes including swimming, cookery, gardening, shopping and social events at the Gateway club. They attend Watford Sea lions club and take part in a swimming gala. One service user attends various social events/disco at least twice a month and sometimes chooses to go to these instead of other planned activity. Other choices include trips to shops, theatre, seeing friends and visiting the family. Both service users have regular contact with their families either by telephone or visiting. A service user stated that he had the opportunity to write the menus but can always have an alternative if he changes his mind. The manager stated that the personal allowances of service users are dealt with by their families. There was evidence of action being taken to minimise identified risks for example in making sure that the washing machine door is closed properly. Staff accompany service users to undertake their various outdoor activities. The inspector noted that great emphasis was placed on service users’interests. Service users were seen engrossed in building models, painting and collecting motorcycle models and reading magazines connected with their hobbies or watching a video.. Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.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 was good. This judgement has been made using evidence available on the site visit. Service users are enabled to undertake activities in the home and in the local community. Their rights are respected and they are offered a healthy diet. EVIDENCE: The evidence under this section was obtained from interviews with service users and staff and from viewing documentation. The inspector viewed the programme of activities of both service users. Both service users stated that they were happy to engage in activities in the home, at the Day Centre and in the community. A service user is employed by Day centre enterprise 3 days a week, attends the power to work course and undertakes other activities on the other days. Another service user attends the Day Centre learning curve where he follows courses on employment, education, interviewing skills and career development. Courses in social skills, cookery, maths and English are also undertaken. Service users are encouraged to participate in activities in the local community. They attend clubs with peers from the Day Centre. They have an opportunity to interact by engaging in activities such as snooker, swimming, Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.R01.S.doc Version 5.2 Page 12 discotheques. They go to the library, cinema and to the local pub every Friday. They attend the Aspire leisure centre. The home was invited to a community barbecue. Both service users are registered to vote. The home supports service users to attend places of worship. Staff also encourage service users to maintain family links. One service user told the Inspector about his visits to his family and how he enjoyed such visits. Both service users have regular contacts with their families. Service users were observed to have freedom in the use of their time and environment. The inspector observed that service users went to their rooms to spend time on their own according to their choice. The menus viewed offered a choice of suitable meals which were balanced and offered variety. The inspector was able to observe the serving of dinner. Service users wanted a different option from the one they had chosen and opted for fried rice and vegetables. This meal was thoroughly enjoyed by service users. Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.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): 18, 19 and 20 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users receive appropriate personal support. The health care needs of service users are met. Service users are protected by the home’s medication policy. EVIDENCE: The evidence was obtained from observation, interviewing service users and staff and from the documentation viewed. The Individual care plan section dealing with the health care needs of service users outlines the personal support required by each service user. Both service users are generally able to care for themselves but may require help with shaving or bathing. The member of staff interviewed stated that service users were enabled to be as independent as possible but may require prompting. Both service users stated that staff were helpful and treated them with respect. The team is multicultural and staff interviews confirmed that they have a good understanding of service users’ cultural backgrounds. The inspector observed a good rapport between staff and service users. Service users communicate their preferences for example what they would like in their packed lunch. On the day of the second inspection it was noted that the menu was altered to meet the wishes of the service users. Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.R01.S.doc Version 5.2 Page 14 Service users are registered with the local GP and can make appointments as and when required. They are also enabled to access health care facilities such as Psychiatrist, dietician, optician and the dentist. Documentation suggested that regular reviews were being carried out. The home has a medication procedure. None of the service users self medicates. The MAR sheets viewed confirmed that the administration of medication was in order. Medication reviews are carried out on a three monthly basis. Some members of staff had followed medication training. It is required that all members of staff undertake an approved medication training course. Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.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 was good. This judgement has been made using evidence available on the site visit. The complaints’ procedure ensures that concerns/complaints from service users and interested parties are acted upon. The POVA policy contributes to service users being protected from abuse. EVIDENCE: The inspector met with both service users and asked them specifically whether they were satisfied with the care provided. Both service users stated that they were happy with the way they were treated and did not wish to make any complaint. The home has a complaints policy in place. The complaints procedure was displayed in the hallway and in service users’ bedrooms. CSCI was informed of an allegation of abuse in the home that was being considered under Harrow’s Protection of Vulnerable Adults Procedure. The CSCI carried out a random visit on 11th July 2006. The purpose of the visit was to check on appropriate procedures and practices in respect of complaints, abuse-prevention, and challenging behaviour management (standards 22 and 23). The requirements made by the CSCI on the visit of the 11th July were addressed on this inspection. The complaint was investigated under Harrow’s Protection of Vulnerable Adults Procedure and was found to be unsubstantiated. Staff interviewed appeared to have an understanding of how to deal with challenging behaviour. As identified on the last inspection Management must ensure that all staff receive training in challenging behaviour from a recognised body. Further work is needed on the home’s prevention of abuse policy, to ensure that it fully complies with standard 23, for instance on service user protection, Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.R01.S.doc Version 5.2 Page 16 GP involvement for injuries, who to notify, and how the procedure links with local borough procedures. All Staff must also undergo accredited training on the Protection of vulnerable adults. The home had carried out risk assessments to cover activities of daily living of all service users. Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.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): 24 and 30 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users live in a homely environment. The home is clean and hygienic. EVIDENCE: The inspector toured the building. The home was observed to be clean and tidy. Both service users stated that they were very happy with their environment. The premises were comfortable, bright, airy and provided sufficient and suitable light and ventilation. The premises are accessible and meet the needs of the current service users. One service user took the Inspector to his bedroom. He was happy with the facilities provided. The service user was looking forward to purchasing a DVD Hand washing facilities are prominently sited. The laundry floor finishes are impermeable and these and wall finishes are readily cleanable Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.R01.S.doc Version 5.2 Page 18 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 was good. This judgement has been made using evidence available on the site visit. Service users are supported by committed staff who have an understanding of residents’ needs and would benefit from training in the identified areas including challenging behaviour. EVIDENCE: Evidence was obtained by interviewing service users and staff and by viewing care plans. Both service users were interviewed and stated that they felt at ease to speak to staff at any time and they felt that staff listened to their requests. During this inspection a service user was discussing with the manager a video player he wanted to buy and another service user was showing the airplane model he had built. The manager had explored local facilities and facilitated service users’ access to activities according to their preferences. This inspection identified that although staff had been briefed about dealing with specific behaviours there was a requirement for staff to follow accredited training in this area from a recognised body. Management must also ensure that all staff follow behaviour modification technique from a recognised body. Both service users attend clubs and day centres during the week. The rota showed that there was generally one staff on duty to attend to the two service users. There are periods for example between 10:00 am and 2:30 pm when Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.R01.S.doc Version 5.2 Page 19 service users are out and there is no staff on duty present at the home. The inspector discussed with the manager the situation when a service user may require or may choose to return home. There must be a contact number in cases of emergency possibly linked to an answering service when there is no staff member present at the home to ensure that service users’ needs are met at all times. The inspector viewed documentation, which confirmed that staff had to obtain satisfactory CRB and POVA and POCA checks prior to employment. They must also have 2 satisfactory current references and show that they are eligible to work in the UK. Interviews with staff suggested that they met with service users as part of the interview process. Staff stated that they had been given a copy of the GSCC code of conduct and practice. The home has a volunteer policy but there are currently no volunteers. Interviews with staff confirmed that they had received induction training and had followed first Aid, Food handling, Fire Safety. This inspection identified that staff must obtain accredited training to Sector skills Council Specification including training on the principles of care, safe working practices, the organisation and worker role, the experiences and particular needs of the service user group and the influences and particular requirements of the service setting. The home has an equal opportunities policy and staff interviewed showed knowledge of the policy. All staff are required to follow equal opportunities training and an accredited medication training course. Management must ensure that each staff member has an individual training and development assessment and profile with a planned programme of dates to undergo training. Interviews with staff confirmed that they were receiving supervision every two to three months. There were no procedures in place for dealing with physical aggression towards staff. Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.R01.S.doc Version 5.2 Page 20 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 and 42 Overall quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users benefit from a well run home. The health, safety and welfare of service users are promoted and protected. EVIDENCE: The evidence in this section was obtained from interviews with the manager, staff and service users and from viewing documentation. The registered manager possesses the NVQ level 2 and has followed a number of training courses. He is currently following the NVQ level 4. He is enthusiastic in exploring facilities and activities available in the locality and has implemented a varied programme of activities, which service users said they enjoyed. The inspector identified that the manager and staff require to undertake training in challenging behaviour and behaviour modification techniques to ensure the welfare of service users. The home was registered on the 27th October 2005. The home is yet to develop an annual development plan reflecting aims and outcomes for service users. The manager must undertake service user surveys and obtain feedback from relatives and stakeholders in the community. Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.R01.S.doc Version 5.2 Page 21 The home had a health and safety policy and staff had undertaken training in health and safety and fire safety and food hygiene. All staff had followed training in First Aid and Infection control. The infection control policy was viewed and staff stated that they had also followed the infection control training. The Gas check was done on 4th September 2006. The manager stated that the electrical system and electrical equipment had been checked as part of the registration process. The home had fitted thermostatic valves and the hot water temperature was adequate. The home had a statement of the policy for maintaining safe working practices. Risk assessments had been carried out in activities involving service users for example the use of knives in the kitchen and in health and safety matters. Staff had not received specific training to meet TOPPS specification on all safe practice topics. Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.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 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 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 3 X 2 X 2 X X 2 X Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.R01.S.doc Version 5.2 Page 23 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 YA23 Regulation 13(4), 15 Requirement Management must ensure, where a service user has a behaviour that challenges the service, that: Up-to-date support guidance is in place for how staff will positively support the service user. . 2. 3. YA23 YA23 10(1), 13(1), 15 13(6), 18 All staff must follow accredited POVA training. Further work is needed on the home’s prevention of abuse policy, to ensure that it fully complies with standard 23, for instance on service user protection, GP involvement for injuries, who to notify, and how the procedure links with local borough procedures. Where staff or a service user receives any form of physical aggression, this must be recorded about in the accident book for transparency purposes. DS0000065181.V311462.R01.S.doc Timescale for action 30/11/06 20/12/06 20/11/06 4. YA23 17(2) sch 4 pt 12 20/11/06 Sudbury Care Homes 12 Binyon Crescent Version 5.2 Page 24 5. YA23 18(1)© 6. 7 YA35 18(1)C 18(1)a YA33 8 YA35 18(1)c Management must ensure that all staff receive training in challenging behaviour from a recognised body. . A policy for dealing with physical aggression towards staff is required. There must be a contact number in cases of emergency possibly linked to an answering service when there is no staff member present at the home to ensure that service users’ needs are met at all times. Management must ensure: 1. That staff obtain accredited training to Sector skills Council Specification including training on the principles of care, safe working practices, the organisation and worker role, the experiences and particular needs of the service user group and the influences and particular requirements of the service setting. 2. All staff are required to follow equal opportunities training and accredited medication training. That Staff receive specific training to meet TOPPS specification on all safe practice topics. The manager and staff are required to undertake training in challenging behaviour and behaviour modification techniques to ensure the welfare of service users. It is required that there are clear guidelines about the use of Behavioural techniques. There must be records of the explanations given to the service user and the service user’s DS0000065181.V311462.R01.S.doc 01/11/06 30/11/06 10/11/06 14/01/07 8 YA42 13(4)b 14/01/07 9 YA42 YA37 18© 30/11/06 10 YA6 YA7 12(2) 12(3) 30/11/06 Sudbury Care Homes 12 Binyon Crescent Version 5.2 Page 25 11 YA35 18© 1and 11 12 YA39 24 consent to the use of the technique. There must also be a record of approval by the manager prior to the use of the technique and of each instance when it is used. The technique must be reviewed regularly to monitor whether it continues to be of benefit to the service user. Management must ensure that each staff member has an individual training and development assessment and profile with a planned programme of dates to undergo training. Management must implement an annual development plan reflecting aims and outcomes for service users. Management must undertake service user surveys and obtain feedback from relatives and stakeholders in the community 14/01/07 14/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA23 Good Practice Recommendations Management should endeavour to ensure that the specific therapist involvements recently advised for individual service users are promptly acquired. The new challenging behaviour policy would overall benefit from being reviewed and made easier to sequentially follow. It should also refer to national good practice guidance. It is suggested that there be recorded guidance on what must be recorded as an incident. 2. YA23 3. YA23 Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.R01.S.doc Version 5.2 Page 26 Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Sudbury Care Homes 12 Binyon Crescent DS0000065181.V311462.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!