Inspection on 12/12/05 for Sunnybrook Close (6)

This inspection was carried out on 12th December 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sunnybrook Close (6) 18/04/07

Sunnybrook Close (6) 06/06/06

Sunnybrook Close (6) 01/12/04

Sunnybrook Close (6) 18/05/04

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Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Sunnybrook Close (6) 6 Sunnybrook Close Aston Clinton Aylesbury Buckinghamshire HP22 5ER Lead Inspector Mrs Maureen Richards Announced Inspection 12th December 2005 09:30 Sunnybrook Close (6) DS0000028528.V259645.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 Sunnybrook Close (6) DS0000028528.V259645.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. Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sunnybrook Close (6) Address 6 Sunnybrook Close Aston Clinton Aylesbury Buckinghamshire HP22 5ER 01296 630038 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) Hightown Praetorian & Churches Housing Association Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 Brief Description of the Service: 6 Sunnybrook Close is a detached property, situated at the end of a cul de sac in the village of Aston Clinton on the outskirts of Aylesbury. ‘The home’ provides care and accommodation for adults with learning and physical disabilities and is registered for up to three service users. The home is run and managed by Hightown Praetorian and Churches Housing. Sunnybrook Close provides single room accommodation for all service users and has been sympathetically refurbished to provide for their needs. There is a private garden to the rear of the property and to the front of the home there is ample car parking space for approximately six vehicles. The home is situated close to public houses, green park and a small local shop. Aylesbury and surroundings areas are accesible by transport. Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection of Sunnybrook took place over seven and a half hours on the 12th December 2005. The inspection consisted of discussions with the service manager, individual discussions with two staff, a general introduction to the three service users, a tour of the building and examining records. No comments cards were received in respect of this service. All of the key standards have been inspected over the two inspections. The progress with previous requirements and recommendations was also assessed and found to have been complied with. What the service does well: What has improved since the last inspection? What they could do better: Service user plans should indicate evidence of service users involvement in their development. Guidelines to support service users with their needs should be dated and show evidence of being reviewed. Service users records should fully explain why an activity has not taken place. All staff must be assessed and deemed competent to administer medication, written records must be maintained on staff files to support this. Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 Page 6 All concerns must be logged as a complaint and records fully completed and maintained to indicate that complaints are being managed effectively. The complaints procedure should be updated and re explained to service users. The home should develop a procedure to the death policy as to who to contact in the event of discovering a death. The kitchen cupboard, which contains hazardous cleaning materials, must be kept locked. The organisation must ensure that staff are not working excessive hours. Staff files must be updated with the required information. New staff including bank and agency staff must be fully inducted into the home and a record must be completed and maintained to support this. The organisation must ensure that all staff have the required mandatory training. The organisation must ensure that staff have regular formal supervision to support them in their roles. Staff at the home must ensure that information pertaining to service users is kept secure and confidential. The organisation must ensure that risk assessments are in place to indicate that access to equipment does not pose unnecessary risk to service users. 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. Sunnybrook Close (6) DS0000028528.V259645.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 Sunnybrook Close (6) DS0000028528.V259645.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): EVIDENCE: None of the above standards were assessed at this inspection. The key standard was assessed as being met at the previous unannounced inspection. Sunnybrook Close (6) DS0000028528.V259645.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&9 Service users plans are detailed and specific in plan of care, which ensures that service users needs are met in a safe and consistent way. Up to date risk assessments are in place which promote the health, safety and welfare of service users. EVIDENCE: All three service users plans were viewed at this inspection. Each service user plan contained a personal details information sheet, a photograph, details of relevant key people involved in individuals care and lives. Each of the plans contained detailed information on how individuals were to be supported with personal care, getting up routines, getting dressed, going to bed, medical conditions including support with medication and appointments, communication needs, support required and involvement with household tasks and laundry. This information was signed dated and showed evidence of being reviewed. Whilst the information within the service user plans was written in the first person there was no signature to indicate service users involvement or to indicate how this information was obtained. Each service user had a separate daily file, which included person centred support plans. Those support plans showed evidence of service users involvement and were updated to Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 Page 10 indicate review and update as goals were achieved. The daily file included separate guidelines on the management of particular medical conditions or programmes agreed by dieticians, speech and language therapist and physiotherapist. None of those guidelines included a date of implementation or evidence of being reviewed or updated. All of the service user plans included a series of risk assessments, which included an indication of the risk, a management plan to reduce the risk and were kept updated and reviewed. The risk assessments included service users signatures. A moving and handling risk assessment was in place for one service user as required. The home has a missing persons policy in place, which was reviewed and updated in December 2005. Sunnybrook Close (6) DS0000028528.V259645.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): 13 Service users are offered a wide range of activities with their individual interests and choices being taken into consideration and made available to them. EVIDENCE: Individual service user plans include a record of what monthly activities have taken place. This includes trips to see Christmas lights, shopping, meals out and trips to local public houses and church services. Each service user plan includes a lifestyle plan of individual planned activities which indicates a wide range of activities are made available to service users. All of the service user plans made reference to service users previous interests and hobbies and current daytime activities and leisure likes and dislikes. The service manager confirmed that issues with neighbours are addressed as they arise and there has not been any other issue in maintaining a neighbourly relationship with the community. The home has its own transport, which is able to accommodate all three service users and staff. Service users are on the electoral roll but due to their reduced abilities and legislative prohibitions no one voted at the recent general elections. Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 Page 12 The activities record indicates that staff are available in the evenings and at weekends to enable service users to take part in activities. However an entry in one service users file indicated that the service user was unable to go for a walk, as there were no staff available. There was no explanation as to why there were no staff available and this must be addressed by the service manager with the staff on duty that day. Standard 15 was not assessed, however service users have had three holidays made available to them this year, including a trip to Disneyland Paris for one service user which included a family member. Photographs are on display in the service users bedroom, which indicates the service users enjoyment of this holiday. Sunnybrook Close (6) DS0000028528.V259645.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): 20 & 21 Medication is well managed which ensures the health and welfare of service users. Records are not fully completed to indicate that staff have been assessed and are deemed competent to administer medication, which could potentially put service users at risk. A policy is in place to ensure that the death of a service user is handled appropriately and with dignity and respect. EVIDENCE: None of the service user group are self-medicating. Service users’ medication is stored in a small locked cupboard in each service user’s bedrooms. Any excess stock is kept in the office in a locked cupboard. A member of staff is responsible for ordering the medication. The medication is ordered monthly and supplied a week at a time to the home. All medication received into the home is recorded on the medication administration sheet and the majority of the medication is supplied in a nomad dosette box. The medication administration records are generally well maintained with some gaps for the administration of supplements. The home has a record for disposal of medication. The storage of medication was well managed. The home does not have any homely remedies, however in the cupboard in the office there were two bottles of sterile eyewash. There was no indication as to who this was for or how it Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 Page 14 should be used. This should be returned to the pharmacy or clear guidelines put in place for its use. The service manager confirmed that all staff attend the care of medicines training and are assessed prior to administering medication. One staff member’s induction pack indicates that this assessment was not completed although this individual was responsible for administering medication. The service manager must ensure that all staff responsible for administering medication have been assessed and deemed competent to administer medication. A record must be maintained to confirm this. The home has a medication policy in place, which was approved in 2005 and is due for review in 2008. The home has a local procedure, which has been developed in conjunction with the organisation’s policy. A recommendation was made at the previous unannounced inspection that an audit of medication by the supplying pharmacy is arranged. Records confirm that a pharmacy inspection took place on the 4th October 2005. The home has a policy in place on the death of a service user, this makes reference to dealing with an unexpected death. The policy was approved in December 2005 and is due for review in 2010. The service manager should include an appendix to this on who staff should contact with contact numbers in the event of thedeath of a service user. A recommendation was made at previous inspections that the organisation includes palliative care training on its staff development portfolio. The service manager confirmed that they have attempted to access this but to no avail. A CD-rom has been purchased and elements of the CD - rom training may be able to be used as training on palliative care for staff. None of the current service user group currently require palliative care at present and it is agreed that this recommendation will be considered complied with at this inspection with the home being able to access the appropriate training from health professionals if and when required. Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 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 & 23 A complaints procedure is in place, however complaints are not being addressed in line with the policy, which potentially could mean concerns are not acted on to, ensure the well being of service users. Policies, procedures and training are in place to ensure the protection of service users. EVIDENCE: The home has a complaints procedure in place, which indicates the stages of a complaint and who to contact. This procedure indicates that complaints will be investigated within 28 days. Service user plans include a pictorial complaints procedure, which should be updated to indicate the change of staff within the home. Service user plans indicate that the complaints procedure was explained to them in 2003. The complaints procedure should be reinforced and explained to service users again as two years is a long time since this last took place. The home has a log of complaints. One of the complaints did not include the outcome of the complaint and this must be completed. A letter of complaint from a family member was found in one service users file dated 21st January 2005. There was no reference to this complaint within the complaints log and there was no indication within the service user’s file if this was investigated, addressed and a letter of outcome sent to the family member. The home has a protection of vulnerable adults policy in place, which was approved in December 2004. This policy is in line with interagency procedures and includes contact details of relevant bodies. The home has a confidential reporting policy and the staff on duty were clear of their role in reporting bad practice and any issue of concern. The permanent staff at the home have had Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 Page 16 protection of vulnerable adults training in February and March 2005. The bank workers have not received this training. The home has policies and procedure in place on the management of service users finances, which was reviewed in April 2005. One service user’s personal finance record and expenditure was checked and found to be correct. Receipts are obtained for all expenditure. Two staff check the contents of the service users petty cash tin daily and sign to confirm this. The service manager confirmed that the organisation carry out an annual audit of service users money and this is also audited during the regulation 26 meetings. Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 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 The home is clean, welcoming, and homely and systems are in place to maintain this to provide a safe environment for service users. EVIDENCE: The home is accessible to service users with a ramp access to the entrance to the home. The home is homely, welcoming, well equipped and maintained. The bedrooms and communal areas are furnished to a high standard and bedrooms are individually personalised. The home was clean and free from odour and the level of cleanliness was maintained to a high standard. At the time of the inspection the home was nicely decorated with Christmas decorations. Since the previous unannounced inspection one of the service users bedrooms and the kitchen/dining area have been decorated. The home has a private secure garden to the rear of the property with the dining area opening out onto a patio area. At the unannounced inspection it was noted that plans were in place to develop the garden area with a sensory garden and a shaded seating area. This has not taken place to date. The garden is uneven in parts and is unsafe for service users to access independently. The service manager confirmed that service users are always accompanied by staff when in the garden. Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 Page 18 A recommendation was made at the previous unannounced inspection that the organisation provides the home with a storage cupboard in the bathroom to store aids, equipment and spare stock. A cupboard has been purchased but to date has not been fitted. The service manager advised that they are considering putting this cabinet in the laundry room as opposed to the bathroom. Standard 30 was not assessed. However a recommendation was made at the previous unannounced inspection that the home place the mop heads in drip trays to ensure that unnecessary damage to the floor and wall does not occur. The area behind the mops has been tiled and buckets are in place underneath the mops. Requirements were made at the previous unannounced inspection that the COSHH cupboard is kept locked at all times. This was found to be locked but the locked cupboard under the sink containing hazardous cleaning materials was unlocked. The kitchen cupboard must be kept locked at all times. A requirement was made at the previous unannounced inspection that the strip light in the kitchen / diner must be cleaned. This has been complied with and systems are in place to keep this maintained. Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 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): 32,33,34,35 & 36 Some of the staff team have the necessary skills and specialist training to meet service users needs. The home has staff vacancies and permanent staff are working excessive hours to cover vacancies, which potentially puts the service users and staff at risk. The home does not have all of the required information available to confirm that safe recruitment practices are in place, which potentially puts service users at risk. Some staff do not have the required mandatory training, which could affect the safety and well being of service users. Staff do not receive regular supervision which could result in them feeling unsupported and stressed which potentially could affect the delivery of care to service users. EVIDENCE: It was observed that staff are accessible and comfortable with service users and make visitors to the home feel welcome. They have developed a good understanding of service users communication needs. The service manager confirmed that staff are reliable and honest. Staff on duty appeared committed and motivated to provide a good quality of care for service users. Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 Page 20 Staff have had training in learning disabilities and in the management of specific medical conditions relevant to the service user group. The service manager confirmed that the home has developed good working relationships with professionals involved in service users care. No comment cards were received from any professionals involved with the home to support this. One of the project workers have obtained an NVQ 2 and one project worker has obtained an NVQ 2 and 3.Two project workers are scheduled to commence NVQ 2 training in February 2006. The service manager confirmed that the organisation has recently obtained its own accredited NVQ assessment centre which should enable more staff to be able to access this training. The home has a registered manager, senior project worker and two night staff project worker vacancies. The home has two project workers on maternity leave. The vacancies are being covered by agency staff on nights and by bank and permanent staff on days. The rota indicates that there are two staff on each daytime shift with a waking and sleep in member of staff on the nightshift. The rota indicates that some members of the permanent staff team are working long days to cover shifts. On the week of the 5th December one staff member worked four long days and two sleep ins and another staff member worked three long days and two sleep ins. Some of the long days were prior to a sleep in shift or following a sleep in shift. Whilst it is acknowledged that the home is short staffed and that permanent staff offer continuity of care for service users, this is unsafe practice, which potentially puts staff and service users at risk. The extra hours worked by the permanent staff must be closely monitored and bank staff and agency used to cover shifts as required. Staff are responsible for the cooking, cleaning and gardening. Team meetings take place monthly and records are in place to support this. Five staff files were viewed at this inspection. Four of the staff files seen included a copy of the application form, copies of two references and confirmation of CRB disclosure and CRB number. One of the files for a bank worker did not have confirmation of CRB clearance. None of the files confirmed medical fitness, contained a photograph and did not include copies of proof of identity as required under schedule 2. Staff files must be updated with this information. The home uses agency staff to cover shifts. The home has received confirmation from the agency that staff have been CRB checked and that two references are on file. The service manager confirmed that new staff are inducted into the home and an induction pack is in place to confirm this. However the induction for one staff member who has been in post at the home for over 12 months was incomplete and there were no records to confirm that all bank staff and agency workers are inducted in to the home. This must be addressed as a priority to ensure the safety of service users. Staff have individual training development plans, which have been updated as required from the previous unannounced inspection. However the training Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 Page 21 records indicate that one permanent staff member in post for over 12 months has not got the required mandatory training and that other members of the team are overdue for updates in some mandatory training. There is no record of any mandatory training for bank staff used at the home. The agency have confirmed that agency staff carry a training card. However there is no record of this at the home and the service manager must ensure that systems are in place to check agency staff training cards to ensure that the required mandatory training is up to date. Some staff have received equal opportunities training and the equal opportunities policy was reviewed and updated in July 2005 as recommended at the previous unannounced inspection. Staff confirmed that they do not receive regular supervision. The supervision records indicate that two of the permanent members of the staff team have had one supervision session in the past 12 months. This must be addressed. Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 Page 22 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): 40 The organisation has up to date polices and procedures in place to support staff practice to ensure the safety and well being of service users. EVIDENCE: Standard 37 was not assessed as the home does not have a registered manager in post. The home has been without a manager since June 2005. The organisation has attempted to recruit into this position but without success. The service manager facilitating the inspection has been overseeing the home during this time. The organisation has planned for a registered manager from another service to manage the home two days a week with the service manager being available for the other three days. This is an interim arrangement, which will be reviewed in three months. The certificate of registration was displayed and needs to be updated by the Commission to reflect the manager vacancy. The organisation has been proactive in reviewing and updating polices and procedures as identified as requiring updating at the previous unannounced inspection. Staff confirmed that they are made aware of relevant policies and Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 Page 23 changes to policies and are expected to sign to confirm that they have read and understood policies. The service manager was able to access the relevant policies as required for this inspection. Standard 41 was not assessed at this inspection but was inspected at the unannounced inspection. A requirement was made at that inspection that the organisation must provide the home with a metal cupboard, which is secured to the wall and lockable to appropriately and effectively store confidential records The service manager confirmed that the filing system at the home was being reviewed and this will be addressed as part of that. In the meantime a further lock has been fitted to the existing cabinet to make service users information secure. It was noted at this inspection that the diary and message book were left out on top of the filing cabinets and were accessible to service users and visitors to the home. The message book contained some information on the outcome of service users appointments or specific matters relating to individuals, which must be kept confidential. Standard 42 was not assessed at this inspection but was assessed at the previous unannounced inspection. A requirement was made at the previous unannounced inspection that risk assessments that relate to safe working practices, specifically for the members of staff who are pregnant must be undertaken each month. This was found to be complied with and all the generic risk assessments were up to date including individual risk assessments for the pregnant staff. It was noted at this inspection that rubber gloves were stored in a cupboard, which was unlocked and accessible to service users. A risk assessment must be put in place to indicate if this practice poses any risks to service users and appropriate action taken if necessary. Washing powder and softener was left out in the laundry room accessible to service users. A risk assessment must be carried out to indicate if access to the washing powder and softener poses any risks to service users. Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 Page 24 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 x x x x x Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 3 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 2 1 1 1 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sunnybrook Close (6) Score x x 2 3 Standard No 37 38 39 40 41 42 43 Score x x x 3 x x x DS0000028528.V259645.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 18 Requirement The service manager must ensure that all staff responsible for administering medication have been assessed and deemed competent to administer medication. A record must be maintained to confirm this. All concerns must be logged as a complaint and records completed and maintained to indicate this. The kitchen cupboard containing hazardous cleaning materials must be kept locked at all times. The extra hours worked by the permanent staff must be closely monitored and bank staff and agency used to cover shifts as required. Staff files must be updated with the information required as outlined under Schedule 2 & 4 (6) All staff including bank and agency staff must be inducted into the home and a record of completed inductions must be kept to confirm this. The organisation must ensure that all staff including bank and agency staff have the required DS0000028528.V259645.R01.S.doc Timescale for action 31/01/06 2 3 4 YA22 YA30 YA33 22 13 13 &18 31/01/06 12/12/05 31/12/05 5 YA34 19 28/02/06 6 YA35 18 31/01/06 7 YA35 18 28/02/06 Sunnybrook Close (6) Version 5.0 Page 26 up to date mandatory training 8 9 10 YA36 YA41 YA42 18 17 13 The organisation must ensure that staff receive regular supervision Information pertaining to service users must be kept secure and confidential. A risk assessment must be carried out to indicate if access to rubber gloves, washing powder and softener poses any risks to service users and action taken to reduce identified risks. 28/02/06 31/12/05 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 4 5 6 Refer to Standard YA6 YA6 YA13 YA20 YA21 YA22 Good Practice Recommendations Service user plans should indicate evidence of service user involvement or an indication on how the information was obtained which involved the service users. Guidelines developed from information supplied from other health professionals should include a date of implementation and review. The service manager must ensure that all staff facilitates activities and that if an activity is unable to take place a record is maintained as to why. The sterile eyewash should be returned to the pharmacy or clear guidelines put in place on its use. The service manager should include an appendix to the death policy on who staff should contact with contact numbers in the event of the death of a service user. The pictorial complaints procedure should be updated and re- explained to service users. Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Sunnybrook Close (6) DS0000028528.V259645.R01.S.doc Version 5.0 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. 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