Inspection on 30/11/05 for Stonesby House

This inspection was carried out on 30th November 2005.

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 28 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stonesby House 30/10/08

Stonesby House 26/11/07

Stonesby House 06/03/07

Stonesby House 04/05/06

Stonesby House 12/01/06

Stonesby House 08/07/05

Stonesby House 04/11/04

Stonesby House 23/04/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOME ADULTS 18-65 Stonesby House 147 Stonesby Avenue Leicester Leicestershire LE2 6TY Lead Inspector Ruth Wood Unannounced Inspection 30th November 2005 11:30 Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 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 Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 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. Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Stonesby House Address 147 Stonesby Avenue Leicester Leicestershire LE2 6TY 0116 2831638 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 Osman Amar Saghir Mrs Sylvia Ann Martin Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration. Date of last inspection 08 July 2005 Brief Description of the Service: Stonesby House provides a service for eleven adults with mental health needs under the age of 65. The home, an extended semi- detached house, is situated on the main Stonesby Road close to shops and other amenities. There is a bus stop near to the home and regular bus service to Leicester and Wigston. There are two double and two single bedrooms upstairs with a further five single bedrooms downstairs. All except one bedroom have full ensuite facilities. The home has a large, open plan lounge/dining room and an additional room, recently added to the building in which service users can smoke. This room is conservatory style with minimal furniture. There are small garden areas to the front side and rear of the property that are predominantly paved. Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection took place on a weekday afternoon between 12.30pm and 4.30pm. Planning for the Inspection took approximately two and half-hours and included a review of the seven additional visits to the home following the original inspection visit on 08/07/05. The original Inspection was arranged to investigate a Complaint and a Vulnerable Adults investigation was also instigated at this time. Several Strategy Meetings have been held and the placing authorities have undertaken their own investigation of some aspects of the complaints made. A further Strategy Meeting is to be held in the New Year. Given the ongoing level of concern with regards to many aspects of this service, a further Inspection visit will be made in the New Year. This Inspection focused on Care Planning and Risk Assessments and service users’ files were examined in detail. Medication records were also examined, as was the current staff rota. Discussion was held with four service users, one staff member and the Deputy Manager. A tour of the home was undertaken and practice was indirectly observed. Three Relative and one Service User Comment Cards were collected at the end of the Inspection. At the Inspection held on 08/07/05 forty-nine Requirements were identified and three good practice Recommendations made. At this Inspection twentyseven Requirements were identified (of which fifteen were outstanding from the original visit) and three new good practice Recommendations were made. What the service does well: What has improved since the last inspection? The Statement of Purpose now accurately reflects the service user group that the home cares for as well as given details of staff numbers and qualifications. There has been considerable improvement made in the level of hygiene and cleanliness particularly in the kitchen and in service users’ bedrooms. Lighting levels are now sufficient in all areas and a number of repairs and improvements have been completed. The management and administration of medication has also improved with staff having received appropriate training and records being accurately kept. A new system to support service users in managing their finances has been instigated and is a great improvement on the previous system. Recorded balances are now an accurate reflection of Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 Page 6 money held. Improvements in record keeping have been instigated; service users’ files were well structured. 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. Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 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 Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 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): 1,5 Significant improvements are still needed in the quality of information about the home available to service users. EVIDENCE: The Statement of Purpose has been modified to accurately reflect the home’s registration status and states that a service is provided for 11 adults with needs arising from mental disorder. The qualifications and experience of staff are also accurately reflected in the new version of the Statement. During the previous Inspection it was noted that reference was made in service users’ files that they had received verbal and/or written warnings. There was no information available to service users or placing authorities as to why and by whom such warnings would be given. A Requirement was made for this information to be clearly documented within the service users’ terms and conditions by 12/08/05. The Registered Provider Osman Saghir submitted a document to members of the Adult Protection Strategy Meeting on 14/11/05 in response. The document submitted appears to be a staff disciplinary procedure with some minor amendments and is not suitable for the purpose of informing service users as to their rights and responsibilities in this manner. Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 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 Care management practice does not ensure that service users’ needs are met neither are they adequately supported in making decisions or taking responsible risks. EVIDENCE: Four service users’ plans were examined in detail. Care needs were discussed with the Deputy Manager, staff and some service users. Care needs were also observed. Not all care plans were dated or signed either by the assessor or service user. The Deputy Manager confirmed that no regular system of review had yet been implemented. Statements which appeared in several service users’ plans as to their level of need and the level of care given were not verified either by discussion with staff and service users or observation. One service user’s plan stated that 28 hours of one to one care was given per week. Discussion with staff indicated that the service user received little direct care, as they were “very independent”. All care plans examined outlined some of the service users’ needs but did not outline a plan of care as to how these would be met. Aims and objectives such as ‘to promote independence’ were stated but no information as to how this was to be achieved and in what areas was given. Likewise areas of risk were identified but no information given as to how risk should be managed. Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 Page 10 Some Agreements placing restrictions on certain activities for service users were still not signed or dated and did not outline reasons for the restrictions or identify when the restriction would be reviewed. Additional visits were made on 25/08/05 and 22/09/05 to inspect the management of service users’ finances and five Requirements were made. A follow up visit was made on 12/10/05 to ascertain if these Requirements had been met. Clear records were in place for all service users who receive support from staff in managing finances and documented balances were found to match actual balances. At this meeting the Registered Provider was required to forward copies of protocols relating to the practice of staff members accessing service users’ accounts on their behalf as previously required. CSCI have not received this documentation. Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 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): 12,14,13,15,17 Service users are supported in maintaining their relationships but they have very limited access to appropriate activities, their diet lacks nutritional balance and variety and unacceptable restrictions are placed on what and when they can eat. EVIDENCE: A number of service users receive regular visits from family members and some are assisted to maintain contact with family either by home staff or by their social worker. Comment Cards were received from three relatives and all stated that they felt welcomed by the staff/owners at any time. Examination of care plans, discussion with service users and staff together with observation indicated that few service users engage in any structured daytime activity. One service user attends a specialist day centre once per week but there was no indication that other service users engage in any structured activity. One service user goes shopping regularly and another will visit local cafes, pubs and the library. Some service users visit the local shop or post office, sometimes with staff or external professionals’ support. There was no evidence that any service user was engaged in any form of adult education. The one service user who returned a Comment Card did not feel that the home provided suitable activities. Observation and discussion with service users Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 Page 12 indicated that few activities were offered within the home. One service user said that they gott “bored and bothered. Two service users commented on how much they enjoyed the Christmas Dinner served in the home with one stating that it was “the best I’ve had really.” Menu Records were not examined on this occasion but lunch served on the day of inspection was lamb chops, mashed potatoes and garden peas. Service users were given a “free choice” for tea, one service user chose two slices of white toast, another a chip and an egg sandwich. No guidance was given to service users as to what options were available until a service user prompted a staff member to give this. The Deputy Manager stated that there was no clear plan in place to monitor the diet of a service user with diabetes. Menu records will be fully examined at the next inspection in the New Year. There has been considerable improvement in the storage of food and standards of food hygiene; this has been regularly monitored during additional visits to the home. Restrictions on the type of food available are still in place in the home. The fridge, freezer and ‘sweets’ cupboard is routinely locked. One service user’s care plan stated that their access to these was restricted, as they did not observe correct hygiene practices and that they ate inappropriate amounts of food. There was no information on other service users’ care plans as to how these restrictions would impact on their freedom to access food as and when they wished. A statement also appeared on service users’ care plans stating that pork products were not served in the home but that service users could purchase these themselves if required. It was not stated how this restriction met the identified needs of the service user. Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 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 There has been considerable improvement in the storage and administration of medication but further improvement is needed in relation to risk assessments and some aspects of health care. EVIDENCE: There were no excessive stores of medication and medication was stored appropriately. The visiting pharmacist had delivered training to staff administering medication and the senior staff member on duty demonstrated a good understanding of their responsibilities in this area. Medication Administration records were accurate and well kept. Documents were in place in response to individual risk assessments for those service users administering some of their own medication. These were not risk assessments but simply stated the safety information given with the medication. There was no indication how any assessment would be monitored and by whom. There was no documented information as to under what circumstances certain service users should be given ‘as required’ medication. Service users’ files examined contained optical prescriptions. One service user’s care plan stated that they had difficult maintaining continence during certain activities. Another service user has an ongoing problem with continence. Advice should be sought from continence advisors or other appropriate professionals in relation to these two service users and the advice received documented. (A fuller assessment of health care will be undertaking at the next inspection in the New Year.) Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 Page 14 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): 23 Continued improvement is required in existing policies and practices to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: The staff member on duty said they were not aware of the home’s policies on challenging behaviour or whistle blowing but stated that staff had received training in dealing with Challenging Behaviour and how to recognise abuse. Documentary evidence of this training was not available. The staff member also demonstrated understanding of the principles of whistle blowing. As detailed earlier in the Report (Standard 7) practices in relation to service users finances have improved. Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 Page 15 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): 24,30 Following considerable improvements service users now live in a reasonably, comfortable, safe and clean environment. EVIDENCE: On the day of inspection all areas were clean and tidy including the kitchen and the majority of service user’s bathrooms. It is still recommended that the floor covering in one bathroom be changed to aid the maintenance of hygiene and a fresh smelling environment. Many repairs have been completed in the home and there is now sufficient lighting in all areas. One service user’s door still requires adjustment to enable them to open it more easily. Another service user’s bedroom requires redecoration and broken floor tiles in the bathroom need replacing. The Inspector acknowledges the effort made by managers and staff to improve environmental, safety and hygiene standards in the home. Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 Page 16 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): 32,36 Inadequate staffing levels and poor supervision compromise the EVIDENCE: Inadequate staffing levels and poor supervision compromise the support that service users receive. The Registered Provider Osman Saghir forwarded a staffing assessment to members of the Adult Protection Strategy Meeting on 14/11/05. This document referred to national minimum standards for staffing hours. As there are no national minimum standards for staffing hours g it is unclear where Mr Saghir obtained these figures. The document did not contain an assessment of service users’ level of need to inform the level of staffing required, neither did it make any reference to the guidance issued by the Residential Forum. An examination of the current week’s rota showed that there were generally two members of staff on duty throughout the week between 8am and 8pm but there was routinely one member of staff on duty between 8pm and 10pm. The rota also showed a period on Friday 2nd December when only one member of staff was on duty between 2pm and 4pm and on Sunday 4th December between 8am and 4pm. The Deputy Manager stated that a staff member had taken leave suddenly on the Sunday and he would ensure this shift was covered. Staff on duty are responsible for all care and meal preparation and some cleaning duties. Some service users assessments and care plans state that they require one to one support. It is difficult to see how this can be delivered given the current staffing arrangements. Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 Page 17 There was no documentary evidence that staff members receive formal one to one supervision on a regular basis. The staff member on duty confirmed that there was no formal supervision of this nature but that the manager was available if they wished to speak with her. The Inspector was unable to examine staff training or recruitment records as neither the Registered Manager nor Provider were available on the day of Inspection. Progress in meeting previous Requirements made in relation to these Standards will be assessed at an additional Inspection in the New Year. Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 Page 18 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): 41,42 There have been improvements in some areas of record keeping and health and safety but further improvements are required to safeguard service users’ interests. EVIDENCE: Information within service users’ files has been clearly organised. A current basic information sheet must be compiled for all service users that includes a photograph of the service user. The Deputy Manager stated that the Registered Provider was gaining assistance from the Health and Safety Inspector in compiling a Control of Substances Hazardous to Health procedure and in completing risk assessments for safe working practices. The Inspector asked a staff member to lock away a bottle of carpet cleaner that had been left in the office. Compliance with these Requirements will be fully assessed at the Inspection in the New Year. Testing of portable electrical appliances was undertaken promptly in response to an immediate requirement made at the first Inspection this year. Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X 1 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 2 X 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 1 13 2 14 1 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 1 X X X 2 CONDUCT AND MANAGEMENT OF THE HOME 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Stonesby House Score X 2 2 X Standard No 37 38 39 40 41 42 43 Score X X X X 2 2 X DS0000028065.V270292.R01.S.doc Version 5.0 Page 20 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 YA5 Regulation 5 Requirement Timescale for action 31/12/05 2 YA6 15 3 YA6 15 4 YA7 17 The reasons why service users would be issued with verbal and/or written warnings must be clearly documented within the service users terms and conditions. Service users and/or their representatives must be made aware of these conditions. Who has the authority to issue such warnings should also be clearly documented. (Previous timescales of 12/08/05 and 07/10/05 not met) The Registered Manager must 31/01/06 ensure that each service user has an up to date care plan, which accurately reflects their current needs and how these needs are to be met. This care plan must be signed by the assessor, the service user and be dated. (Previous timescales of 19/08/05 and 14/10/05 not met) The Registered Manager must 31/01/06 ensure that a system of regular review of service users plans is implemented. Clear protocols must be in place 13/12/05 stating which staff members can DS0000028065.V270292.R01.S.doc Version 5.0 Stonesby House Page 21 5 YA7 13 6 YA9 13 7 YA12 16 8 YA14 16 9 YA17 16 10. YA17 16 access money from service users’ accounts, that service users have given permission for this and the placing authority has given their agreement to this practice. Copies of these protocols must be forwarded to CSCI. (Previous timescales of 05/09/05, 04/10/05 & 12/10/05 not met.) Restrictions on service users choices must be clearly documented within service users individual plans together with the reasons why these restrictions have been imposed. All such documentation must be signed and dated by the service user and the assessor (Previous timescales of 08/01/05, 12/08/05, 14/10/05 not met). Risk assessments must be put in place to ensure that service users are supported to take responsible risks without placing themselves in unnecessary danger. (Previous timescale of 19/08/05 not met.) The Registered Manager must identify opportunities for service users to participate in appropriate activities or education. The Registered Manager must identify opportunities for service users to engage in appropriate leisure activities based on their own interests and abilities. The Registered Provider must ensure that a varied and nutritious diet is available for all service users, which reflects their health, cultural and religious requirements. Any restrictions placed on when service users can access food must be clearly detailed in their DS0000028065.V270292.R01.S.doc 31/12/05 31/12/05 31/01/06 31/01/06 31/12/05 31/12/05 Stonesby House Version 5.0 Page 22 11. YA17 16 12. YA17 16 13 YA19 13 14 YA20 13 15 YA20 13 16 YA23 13 individual care plans together with the reasons such restrictions are in place. (Previous timescales of 12/08/05 & 14/10/05 not met) Any restrictions placed on where service users can eat must be clearly detailed in their individual care plans together with the reasons such restrictions are in place. (Previous timescales of 12/08/05 & 14/10/05 not met) Any restrictions placed on what service users can eat must be clearly detailed in their individual care plans together with the reasons such restrictions are in place. (Previous timescales of 12/08/05 & 14/10/05 not met)` Appropriate advice must be sought for the two identified service users experiencing problems with continence. The nature of the consultation and advice given must be documented. Individual risk assessments must be completed for those service users administering some of their own medication. These must be regularly monitored and reviewed. (Previous timescales of 12/08/05 and 30/09/05 not met) The reasons why a service user may be given ‘as required’ medication must be clearly detailed in their care plan. A policy detailing the appropriate response to challenging behaviour by care staff must be written. This must include details as to how more vulnerable residents are to be protected. (Previous timescales of DS0000028065.V270292.R01.S.doc 31/12/05 31/12/05 31/01/06 31/12/05 31/12/05 31/01/06 Stonesby House Version 5.0 Page 23 17 YA23 13 18 YA23 13 19 YA24 23 20 YA24 23 21. YA24 23 22. YA33 18 23. YA34 17 24. YA40 17 25 YA41 17 26/08/05 and 14/10/05 not met.) A policy on whistle blowing must be written and implemented within the home. (Previous timescales of 26/08/05 and 14/10/05 not met.) The Registered Person must ensure that all staff are aware of the Multi- Agency policy relating to the Protection of Vulnerable Adults from Abuse. (Previous timescales of 26/08/05 and 14/10/05 not met.) The identified service user’s door must be repaired to ensure that it can be opened easily. (Previous timescale of 14/10/05 not met) The identified service user’s bedroom must be redecorated. (Previous timescale of 31/10/05 not met) Broken floor tiles in the upstairs bathroom must be repaired or replaced. (Previous timescales of 26/08/05 and 07/10/05 not met) The Registered Person must ensure that there are sufficient staff on duty at all times to meet the needs of residents. (Previous timescales of 08/07/05 and 20/09/05 not met) The Registered Person must obtain Criminal Record Bureau checks for all staff working at the home. (Previous timescale of 05/09/05 and 14/10/05 not met) The Registered Person must ensure that the homes policies and procedures are appropriate to the service users living there. The Registered Manager must ensure that each service users’ file contains the information as DS0000028065.V270292.R01.S.doc 31/01/05 31/01/05 31/12/05 31/01/06 31/01/06 30/11/05 31/12/05 31/12/05 31/12/05 Stonesby House Version 5.0 Page 24 25. YA42 13 26. YA42 13 27 YA42 13 detailed in Schedule 3 of the Care Home Regulations. A Control of Substances Hazardous to Health Assessment must be undertaken and made available for inspection. (Previous timescale of 19/08/05 not met) The Registered Person must ensure that all substances hazardous to health are stored appropriately at all times. Risk assessments dealing with safe working practices in the home must be completed. (Previous timescale of 07/10/05 not met) 31/12/05 30/11/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA9 YA24 Good Practice Recommendations It is strongly recommended that key staff receive appropriate training in care planning. It is strongly recommended that key staff receive training in risk assessment. It is strongly recommended that the floor covering in the identified service user’s bathroom be replaced for reasons of maintaining hygiene and a pleasant odourless environment. Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Stonesby House DS0000028065.V270292.R01.S.doc Version 5.0 Page 26 - 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. 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