Inspection on 09/09/08 for Sydenham Terrace

This inspection was carried out on 9th September 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sydenham Terrace 11/08/09

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

Extracts from inspection reports are licensed from CQC, this page was updated on 20/03/2009.

CARE HOME ADULTS 18-65 Sydenham Terrace 3 Sydenham Terrace South Shields Tyne And Wear NE33 3RY Lead Inspector Carole McKay Key Unannounced Inspection 9th September 2008 14:00 Sydenham Terrace DS0000071689.V371739.R02.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 Sydenham Terrace DS0000071689.V371739.R02.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. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sydenham Terrace Address 3 Sydenham Terrace South Shields Tyne And Wear NE33 3RY 0151 651 1716 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) Potensial Limited Miss Wendy Cairns Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only -code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Learning disability - Code LD, maximum number of places 6 The maximum number of service users who can be accommodated is: 6 Date of last inspection Brief Description of the Service: Sydenham Terrace provides ordinary housing for six people who have a learning disability. The home is registered to provide personal care. Nursing care cannot be provided but district-nursing services can be used as required. The home is a large three storey terraced house and comprises six single rooms. There is a lounge and a spacious kitchen/dining area. There are two bathrooms and two toilets and these are located on the first floor, close to bedrooms. As access to the first and second floor is via a flight of stairs the home would not be suitable for people who use a wheelchair. The home is situated within walking distance of the town centre of South Shields close to a number of local amenities such as shops, public houses, places of worship, parks and the beach. There are bus stops nearby and the home has its own transport, which is shared with another nearby home owned by the same proprietor. The fees payable range from £ 502.23. per week. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. In line with current CSCI policy on ‘Proportionality’ the inspection focused upon a number of key standard outcomes for service users. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on 21 and 22 January 2008. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service. The Visit: One unannounced visit was made on 9 September 2008. During the visit we: • • • • • • • Talked with people who use the service, staff and the manager. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. Left surveys for staff and service users to complete. Some of these were returned in time to be included in this report. We told the manager/provider what we found. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Provide the people who live at the service with an up to date contract so that they understand their rights and responsibilities. Improve service user plans so that people enjoy more individualised care and support with social needs. Describe how medical conditions affect service users in the service user plans. This will help staff provide support to service users. Up date procedures and train staff in these so that service users receive consistent care and support. Make sure that full checks are carried out when new staff are recruited so that the people who live at the home are safe. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 7 Provide staff with comprehensive induction training so that the people who live at the home are supported by well informed staff. Make sure that the staffing arrangements and rotas are designed to meet the needs of the service users, so that they receive support when they most need it and can plan more individualised routines. Make sure that the manager and staff have job descriptions so that they are clear about how they are expected to support service users. Use up to date risk assessment tools and procedures so that service users are kept safe. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live at the service have had their needs assessed, but they do not have a written contract with the current provider. EVIDENCE: At the last inspection a requirement was made to ensure that service users’ needs were fully assessed prior to coming to live at the home. Since that inspection a full assessment has been carried out for the person admitted at that time. No further admissions to the home have been made. The files show that the home receives detailed assessments from other professionals involved in the lives of service users. The manager was also required to write to the person admitted to confirm that the home could meet their needs. This has been done. The people living at the home have a written contract with the original providers of the service. Copies of these are included in the files that were examined. The current providers took the home over in March 2008, but have not yet issued contracts to service users. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has begun to support people to develop more individual care plans. Risks to do with safety are assessed and managed. EVIDENCE: Following the last inspection requirements were made to do with providing detailed and up to date guidance to staff in service users plans, and carrying out risk assessments. Two of the files were examined in detail and other service user files were examined for specific matters. These files contained detailed risk assessments and management plans. Support plans are in place to enable service users to be more independent, but the manager acknowledges that this still needs to be developed further. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 11 However the home supports decision making through regular recorded meetings with service users. The service user plans also identify the strengths that people have and ‘ This is Me’ workbooks are included. These are used to help the people who live at the home to identify the positive aspects of their lives and personal goals. These plans are in the early stages and more needs to be done to develop real plans towards meeting personal goals and managing any associated risks. People living at the service who returned surveys responded positively that they are able to make decisions and do the things they want to do. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has begun to support more individualised lifestyles though this needs to be developed further. EVIDENCE: One of the people who live at the home has, as part of the service user plan, an ‘essential lifestyle plan’, that was developed during a stay in hospital. The manager said that they have adopted this approach to the social care assessment and care plan process for people in the home. For example the plans have sections entitled - ‘what we plan to do, like to happen, now / later how I communicate, how I get to different places, support required. One service user had identified that taking up knitting and sewing would be an interest, and this had been arranged. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 13 The manager said that staffing shortages had restricted the extent to which they had been able to develop this area. A planned short holiday to Blackpool had had to be cancelled due to staff shortages. There was no evidence in the service user plans of programmes of social activity. But service users are supported to go shopping at weekends. One service user does not have regular structured daytime activities. This person was in the house for the duration of the inspection and was not at any time, other than mealtime, constructively occupied. A lot of this person’s time was spent rocking in a chair and asking staff repeated questions. Most people have somewhere to go out to each day. One person described this as ‘work’ and said that she enjoyed this. The main meal was taken at 4pm and this was the focus of social engagement between staff and among service users. The people living at the home talked to each other and to the staff. Choices and decisions were encouraged and service users eagerly helped with table preparation and clearing away. Other than this people spent most of the early evening in his or her own rooms. One service user had a bath and got into nightclothes at 6:45pm. The manager reminded the person that it was time to do so, and the person responded willingly to this prompt. The manager said that this is the person’s usual routine. One other person came down for supper at 7:50 pm. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health care is assessed and detailed care plans are in place using a medical model. These do not make use of specialised tools and are not so person centred. EVIDENCE: Following the last inspection a requirement was made for service user to receive regular health checks. The files examined showed that arrangements have been put in place for this to happen. There is evidence that the home and the people who live there receive a good level of support and information from the involved health specialists. The service user plans have detailed assessments and supporting information to do with the physical and psychological health needs of service users and general functioning. There are plans for assistance with personal care needs, where this is necessary. For example a detailed bathing plan is in place for one person. But Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 15 the risk assessment for use of a bath aid has not been updated since moving from another service. One person is at risk of falling and a risk assessment has been carried out and precautions for managing stairs are in place. The home has not used a specialised falls risk assessment. Some medical references are not explained clearly enough in terms of what they may mean for the individual. An ongoing health problem is being actively followed through for one of the service users. This person’s weight is being monitored and he is being encouraged to take a high calorie diet. There is no evidence that staff have taken advice or training in diet and/or nutrition. The plan does not show the service user’s preferences. Following the last inspection of the home a requirement was made to address secondary dispensing of medication. This has ceased. Also the manger was required to provide guidance specific to ‘as and when’ medication. This guidance is in place. Arrangements for service users to give their consent to have medication managed by the staff are included in the records. The service has written medication procedures and step-by-step procedures for the administration of medications. The procedures are those of the previous provider. The manager said that she was expecting new procedures to be issued by the new providers. The staff have had external training in handling medication but there is no evidence that staff are assessed as competent in following the home procedures. The home uses a code system on the medication administration record, (MAR). This means that the administration sheet has codes that cross reference to another record chart of all medicines that have been received into the home. One anomaly between the two records was identified despite the record being checked and countersigned. This had not led to an error in medication, but the use of codes could increase the risk of this happening. Medicines are securely stored. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has procedures to protect service users and to deal with complaints. Some of these are user friendly but are not comprehensive and up to date. EVIDENCE: Since the last inspection the home has introduced a pictorial booklet to help service users to think about the support they need. Some completed and signed examples of these were available. The complaints procedure is user friendly with pictures and easy to read type. It is accessible with a copy on the wall in the kitchen and in each person’s service user plan. But this needs to be updated to reflect the change of ownership of the home. No complaints have been received by the home. CSCI has not received complaints in respect of the home since the last inspection. The home has a written step-by-step procedure for handing over personal allowances and for assisting with shopping. Monies belonging to service users are held in a lockable cash box and individual amounts kept in wallets with envelopes of receipts that are numbered. One receipt had items not accounted for in the money record for the service user, and the amount on the record for razor blades did not match Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 17 the amount on the receipt. This was a possible copying error, as the amounts were very similar. The service user was in credit for 70 pence. But staff should avoid putting items not for service users on the same receipts and this should be added to the written procedures. The service has safeguarding procedures, including whistle blowing, which were drawn up by the previous owners. The new owners, Potensial, have a management of challenging behaviour policy. This defines physical intervention and offers a good practice guide to staff. But staff have not been trained in these policies yet. There is a policy to do with consent and professional boundaries guidance. The manager said that they do not have a copy of the local authority procedures for safeguarding. The staff still refer to the OTUS policy and procedures. These do not describe or link with any local authority procedures. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe, comfortable and clean home. Further work is being carried out to ensure on going safety. EVIDENCE: Following the last inspection the home was required to provide dining chairs. These have been provided and are of good quality. One of the bedrooms had not been properly heated. This has been attended to and the room was not noticeably cooler than other rooms. The temperature is being monitored. The earlier requirement that radiators have guards fitted has been addressed in part on the basis of risk. There is evidence in the report from the provider’s representative following a recent visit, that this matter is being progressed. Handrails have been fitted to the stair - case in response to the risk to one of the service users. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 19 Some of the rooms have been redecorated and the bedrooms of the people who live at the home are to their personal tastes. Cleaning schedules are followed and the home is clean and smells fresh. Staff have had training in infection control. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35, Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staffing levels ensure that the basic needs of service user are met, but the structure of the rota is not linked to the outcomes for service users. Recruitment of and training for new staff is not clearly planned and accounted for. So it is not clear how this links with service users’ needs. EVIDENCE: Since taking over the service the provider organisation has not issued staff with new contracts and job descriptions. Staffing arrangements are complicated and governed by external needs. In that all the staff who work at this home (apart from the manager), also work at a nearby home owned by the same provider. Staff work a mix of shifts made up of long days, split shifts and sleep in shifts. The manager works three long days and sleep over shifts in succession and a half shift on a Friday. Some of the care staff also work long days and sleep over shifts in succession. There are no domestic, kitchen or administrative staff. Care staff undertake all duties and these include driving duties Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 21 associated with taking people who live at the home(s) to day services. Four staff are designated as drivers. In surveys two staff reported that staffing shortage affects the support they are able to provide to the people who use the service. One person said that it sometimes prevents one person from receiving the full quota of an additional funded fourteen hours per week of care. The general shift pattern results in one staff on duty through the day Monday to Friday, with a second person on duty from 7.30am to 10.30am and from 3.00pm to 9.00pm. At weekends two staff are on duty all day. The manager of the ‘sister home’ manages staff recruitment and training for both establishments. Wendy, the manager at Sydenham Terrace, said that she does not interview staff. There is no evidence that service users are involved in interviewing staff. The files for the two staff most recently recruited were examined. There was no evidence that these people had completed an application form. But Wendy explained that these were handled at head office. Typed notes were included to indicate that head office had confirmed clearance of the criminal record check, but no details were included and the typed note was not signed. Both files had typed health statements but these were not signed. The staff files had an induction workbook pack for each person. The tick boxes had ticks entered in them, but there was no name or signature by the supervising person or manager in either of these. The staff training file was examined. There was evidence that longer serving members of staff had undertaken training in those subjects that are required, but some updating of this training is due. Wendy said that the training schedule is being reviewed by head office. Some staff had received training in other areas, such as protection of vulnerable adults in 2007. Two staff files contained staff development plan documents, but these had not been completed. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The aspects of the home that are well managed ensure service users’ safety. The manager is not clearly accountable for all aspects of the home’s running. EVIDENCE: Since taking over the service the provider organisation has not issued staff with new contracts. This includes the manager, who said she did not have a job description. The manager has achieved the NVQ level 4 qualifications in management and care as well as the Registered Managers Award. Although Wendy has undertaken some further training since becoming qualified she does not have a forward plan for further training and development. Although she is the registered manager for the home Wendy does not have a remit for staff training and recruitment. When asked about her role as Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 23 manager Wendy said that she felt more like care assistant than a manager, as most of her time is spent on day-to-day household tasks. Wendy’s views about the amount of time she has for management of the home are reflected in the recent monitoring visit report from the representative of the provider. The provider organisation ‘ Potensial’ has delivered new procedures to the home, but not all items are covered. Also, as yet staff have not been trained in these new procedures. Staff still refer to the procedures they are familiar with, from the previous provider of the service, for most things. The new provider has not yet fully established its system of quality assurance. But a monitoring visit by a representative of the organisation took place on 27 August 2008. The report from this visit was available. It is comprehensive and indicates several areas for action and improvement, namely- staffing, staff training, procedures and records, formats for supervision, pictorial surveys for service users, updating the statement of purpose and service user guide, storage and mail. The manager said that the health and safety workbooks that staff are asked to complete have been sent for marking but the results are not yet known. The fire logbook examined confirmed that fire alarms are tested each week and service users confirmed this. A fire risk assessment has been completed for the building. Accidents are recorded. The home has contracts for maintenance and safety checks for mains services and appliances, apart from the bath chair. In house cleaning and safety checks are in place. An environmental health officer visited the home earlier in the year and one recommendation was made. This has been acted on. Routine safety checks are carried out. Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 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 Standard No Score 1 x 2 3 3 3 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 1 32 2 33 2 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 2 13 3 14 2 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 2 x 3 3 x 2 x Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 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 YA5 Regulation 5 Requirement The registered provider must issue to each service user the terms and conditions in respect of the accommodation provided. The registered manager must arrange for the bathing assessment and management plan for use of the bath chair to be updated. Staff must receive training in diet and nutrition to support people who are at risk of poor nutrition. The registered provider must provide an up to date and accessible complaints procedure to each service user. The registered provider must issue staff with up to date guidance to do with safeguarding service users from abuse and handling safeguarding referrals. The registered provider must review the staffing numbers and staffing deployment to ensure that shift patterns support service development and service user’ needs. Timescale for action 30/11/08 2. YA18 13(4)(c) 14/11/08 3 YA18 YA32 18 31/12/08 5 YA22 22 31/12/08 6 YA23 13(6) 31/12/08 7 YA33 18 31/03/09 Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 26 8 YA35 18(1)(c) 9 YA37 9 10 YA37 18(1)©(i) 11 YA42 23(2)© The registered manager must ensure that staff receive thorough induction training and have been signed off as understanding this learning. The provider must review the manager’s job description and learning and development plan to ensure that she is competent to act and be accountable in line with her registration with CSCI. The registered manager must ensure that staff are trained in and understand their employers’ policies and procedures. The bath chair must be routinely serviced in line with the manufacturers recommendations. 31/12/08 31/12/08 31/03/09 31/12/08 Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 27 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 YA6 Good Practice Recommendations To consolidate the work done so far the service user plans should be developed further, with particular reference to the social care needs of service users and any associated risks. The service should develop more individualised programmes of social, vocational, educational activity and domestic routines with the people who use the service. The service should use a specialised risk assessment tool for the prevention of falls. In service user plans references to medical conditions should be explained in ways that make it clear how the individual may be affected. Staff should have their competence to administer medication periodically assessed by the manager. The provider should review and update the existing policies and procedures for the safe administration of medication in the home to avoid the use of codes. The home should obtain copies of the Local Authority Safeguarding procedures. The procedures for staff to follow when assisting service user with personal monies should be reviewed to ensure best receipting and recording practice. Staff should be issued with up to date job descriptions. The manager should record the date and outcome of the recruitment CRB checks in detail on staff files using a standard form such as the CSCI example. Health declarations should be signed and dated. 2 3 4 5 6 7 8 9 10 YA12 YA14 YA16 YA18 YA18 YA20 YA20 YA23 YA23 YA31 YA34 Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sydenham Terrace DS0000071689.V371739.R02.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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