Inspection on 08/01/08 for The Eadmund

This inspection was carried out on 8th January 2008.

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

Other inspections for this house

The Eadmund 13/11/06

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 The Eadmund 68 & 70 Brighton Road Coulsdon Surrey CR5 2BB Lead Inspector Barry Khabbazi Key Unannounced Inspection 8th January 2008 8:30am The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Eadmund Address 68 & 70 Brighton Road Coulsdon Surrey CR5 2BB 020 8645 2680 020 8668 6656 sara.lock@nellbenltd.com 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) Nellben Limited ****Post Vacant**** Care Home 15 Category(ies) of Learning disability (11), Physical disability (4) registration, with number of places The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th November 2006 Brief Description of the Service: The Eadmund is a residential care home for adults with learning disabilities. The home is also registered to provide a service to people who also have a physical disability, and has a number of built in adaptations to facilitate this. There is level access to the front entrance and rear of the building. In those bedrooms identified for the use of people with disabilities there are wider than normal automatic opening bedroom doors, remote opening windows, freemoving tracking hoists in bathrooms, and electrical outlets at a level that that can be accessed from a wheel chair. There is also a height adjustable work surface in the kitchen. The Eadmund is comprised of two semi-detached houses with a shared drive affording a number of parking spaces. The home is situated in Coulsdon between the town centre and Purley, and facilities from both these areas are therefore within a few miles. The home is registered to provide a service to up to 15 people within the two buildings. All bedrooms are single with en-suite facilities and many also contain their own shower. Bedrooms either meet or exceed the room size standard of 12 sq. metres. Each of the two buildings that comprise the home have their own garden, lounge, dining room and kitchen, as well as a quiet area. The home has recently been renovated, and as a result is newly refurbished and re-decorated throughout. There is also an accessible patio in each garden which takes up about one quarter to one third of the garden. The rest of the garden to each building is raised and not currently fully accessible. The fees currently start at £1600 per week The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key Standards identified throughout this report were assessed at this inspection. This inspection also focussed on following up on previous requirements and recommendations, and any new issues arising. Since the last key inspection the previous manager has left and a new manager has started. This inspection was unannounced and started early in the day to allow the residents to be met, before they went to their day activities. The manager was on leave but the deputy manager was very able to provide the management information required and was therefore interviewed. Time was spent with the service users, and records, policies, care plans, and the building were also examined. The home was found to be generally well run and no areas of serious concern were identified. The staffing Standard however had many shortfalls, such as staff supervision, staff qualifications and staff references. These shortfalls combined created a grater shortfall under that staffing section and also may have impacted the outcomes of the care planning Standard where standards had also fallen. During the inspection, service users said they liked the home and the food was okay. Where communication was limited by the service user’s disability, those service users appeared relaxed and contented. When this was not the case staff were seen to be supportive and respond to service users’ needs appropriately. What the service does well: Bedrooms either meet or exceed the room size standard of 12 sq. metres. As doing the NVQ is mandatory for all staff at this home, this should ensure that the minimum number of staff required to have a NVQ is either always well met or in the process of being met. It is expected that as the new manager settles in and as requirements are met, that further areas of good practice will be developed and/or identified. The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Eadmund DS0000067667.V343944.R01.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 The Eadmund DS0000067667.V343944.R01.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): Standard 2 and 5: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users’ needs are assessed before they start at the home to ensure that all needs are known by the staff. The service users rights are enhanced by having an individual contract with the home. EVIDENCE: The file of the newest service user was examined and this contained the care management assessment and care plan as required by this Standard. The home’s person centred plan was also present and had been drawn from this, the home’s own assessment of the service user, and the service user’s own input. The last key inspection report contained the following recommendation under Standard 5: Contracts should contain reference to the identified room to be occupied. This had occurred by the time of the last random inspection and this recommendation is therefore now met. The Eadmund DS0000067667.V343944.R01.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): Standards 6, 7, and 9: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Plans of care do not record all needs and how they are to be met. Service users are supported to make decisions about their lives. Risk assessments are not available for all restrictions of liberty and do not contain all the information required. Including this information could reduce unnecessary restrictions of liberty for the service users. EVIDENCE: The last key inspection report contained the following requirement under Standard 6: Care plans must contain all the elements required under Standard 6, namely those set out under Standard 2.3, and in particular cultural and religious needs. The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 11 The care plans {called action plans} examined at the following key inspection had been amended to contain all the elements listed under Standard 6 and 2.3. This requirement was then met. However since that time the format has changed to a person centred approach. While this is seen as positive as person centred plans record a resident’s needs from their own perspective, these new specific plans did not contain all the elements required under the Standards, for example education training and work. In addition and more importantly, these plans did not always describe how to meet the needs that were identified. For example, how exactly to provide support with specific personal care needs. Even if the original care plans that did meet the Standard are still in the building these were not available to staff to provide the information required. The following requirement is therefore needed again but for different reasons: Care plans must contain all the elements of need required under Standard 6, and record guidance how to meet them. It is suggested only, that one other way this requirement could be met would be for the home to create a separate list of needs and how they are to be met. This would then allow the person centred plans to be the main document that is used to promote care in a way the residents’ prefer, and the care plan list could provide clearer and more accessible guidance to staff about how to meet specific needs. Service users were observed to be supported by staff to make choices and guidance in making appropriate and informed choices was observed at this inspection. Choices are only limited through involving the service user and relatives where appropriate. This is always through a risk assessment process and recorded in the service user’s file. The last key inspection report contained the following requirement under Standard 9: Risk assessments must be produced where any restrictions of liberty or pre-planned restraints are assessed as necessary for the protection of service users. These risk assessments must also contain details of how training and other options have been explored, and the involvement of relatives or independent advocates. Risk assessments were available but not for all restrictions of liberty, for example the kitchen and front door are kept locked but no risk assessments for this were available. In addition risk assessments did not contain a section referring to details of how training and other options have been explored. This information is needed, as it is required under Standard 9 and would also provide evidence that all other options had been explored before a restriction of liberty is employed. This requirement remains unmet. The Eadmund DS0000067667.V343944.R01.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): Standards; 12 13, 15, 16, and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have opportunities to be part of the local community. This promotes inclusion and quality of life. Service users are supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Service users’ rights are respected and responsibilities recognised. The food provided is sufficient in quantity, and it is sufficiently nutritious which is important to ensure good health. The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 13 EVIDENCE: Basic money awareness training has occur, other educational activities occur for example one service user attends a computing course. There are currently no service users at this home engaging in employment or voluntary work. Access to the community is supported by the home having its own wheelchair accessible vehicle. Places like the local parks, cafés, church and shops are accessed. This happens in the evenings as well as the weekends. There is an open visitors policy and records showed that suitable arrangements are in place to enable service users to maintain good links with their families and friends. Staff were observed to be respectful of service users’ wishes and choices. Daily routines and house rules appear to promote independence and individual choice. Meals, for example, can be taken where and when service users want depending on their own activities planned for the day, and service users go to bed and get up when they want. This is done within the context of enabling service users to attend appointments and other commitments. Menus were observed to provide a reasonably varied diet and this was balanced with informed service user choice. Service users were seen to be able to take their meal when they wanted and to be given as much time as they wanted to finish eating. Choice of where to eat is also provided. Cultural preferences and dietary requirements are catered for as needed. Service users spoken to say that they liked the meals served at the home. The Eadmund DS0000067667.V343944.R01.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): Standards 18, 19, and 20: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is usually carried out in a way that residents prefer so that dignity and choice are maintained. Service users’ physical health needs are met by this home. This ensures that the residents’ physical health is well maintained and therefore the quality of life experienced is also maximised. Service users’ are now protected by the home’s medication practice and procedures. EVIDENCE: Personal care is provided in private, and timings of this are also flexible. The home provides consistency and continuity through designated key workers. The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 15 A baby monitor is used to monitor a service user at night. The monitor receiver was on, in the dining room, until 9.30 at the last random inspection. This meant that other service users and visitors in the dining room overheard any private noises in the service user bedroom, removing any dignity and privacy. A requirement was then set under Standard 18, which refers specifically to dignity and respect as follows: To promote dignity and privacy, the position of the baby monitor must be moved from the dining room, to a more suitable area that will allow the monitor to be only listened to by staff. The monitor is now turned off before any residents get up. This meets the requirement set. Service users are registered with a local GP practice and have access to other NHS facilities as necessary such as a dentist, optician, chiropodist, and “well woman” clinic. District nurses and other healthcare professionals attend when required. Evidence was seen of regular monitoring of service users’ health. The service users are registered with a local G.P and have regular check ups. A record of all appointments and check ups are kept. The manager demonstrated knowledge of the health status of individual service users. None of the current service users are able to completely self medicate. However, procedures and a lockable space in service users’ rooms are present to facilitate this where appropriate. Medication profiles and clear medication administration record sheets were seen in records sampled. Medication is either kept in a lockable space in the residents room or securely in a locked metal cabinet fixed to the wall. The last key inspection report contained the following requirement under Standard 20: All staff must have approved and accredited medication administration training. Staff had previously all received medication training from the previous manager. This does not meet the minimum Standard or the requirement set, as both the requirement and the Standard state clearly that this training must be approved and accredited. Since that time the pharmacist has provided the training required and this requirement is now met. The last key inspection report also contained the following recommendation under Standard 20: Consent to medication should be sought from the service users. This has now implemented and this recommendation is now also met.. The Eadmund DS0000067667.V343944.R01.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): Standards 22 and 23: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are generally managed well so that service users feel their views are listened to. Service users are generally protected from abuse or self harm through the home’s protection policies and procedures. EVIDENCE: There had been one complaint since the last inspection which has been resolved. The home has a complaints procedure including a minimum response time of less than 28 days, details of the Commission and this is also available. The last key inspection report contained the following requirement under Standard 23: The restraints policy must be expanded to give staff guidance about how to restrain a resident safely {and then record the incident}, where the home’s duty of care requires them to restrain to protect the resident or other residents from harm. This policy had been updated to include the missing elements identified by the following random inspection, and now therefore meets the minimum standard. This requirement is met. The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 17 The last key inspection report contained the following recommendation under Standard 23: The home’s policies should include a directive to staff precluding them from being involved in the making of, or from supporting residents in making wills. This policy had been updated to include the missing elements identified by the following random inspection. This requirement is met. The home has a Gifts Policy, a Wills policy, a Whistle Blowing policy, and Restraints policy and guidance, which includes appropriate record keeping guidance. The home has a copy of Croydon’s Vulnerable Adults Policy. The Eadmund DS0000067667.V343944.R01.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, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment and furniture generally meet the residents’ needs, and the environment does generally promote the residents well being. The home is hygienic and clean. This environment therefore facilitates the service users’ health and emotional well-being. EVIDENCE: There was suitable lighting and ventilation. The grounds were well kept, and accessible to the current service user group. There are ramps on the ground floor where required and this floor is reasonably wheelchair accessible. Maintenance for the home is provided on an as required basis. The overall condition and décor of the home was reasonable. The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 19 The premises were bright, airy and clean, and free from offensive odours. There was some cleaning required at the start of the inspection but this was being dealt with as I arrived. The home has specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, storage and preparation of food, and dealing with spillages. Protective clothing was observed to be present. Laundry facilities have easily cleanable non-permeable floors and walls. The Eadmund DS0000067667.V343944.R01.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): Standards 32, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users are not currently supported by a staff group where 50 or more have the required qualifications. Achieving this raises the quality of staff, their knowledge and their practices. The home’s recruitment procedures generally protects the residents through vigorous staff vetting. However some references were missing. Staff receive induction and foundation training to ensure that they are appropriately trained although this may need to meet a higher standard. The supervision frequency does not meet the minimum standard required. The service users do therefore not benefit from a well supervised staff team. The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 21 EVIDENCE: Only 3 staff currently have a NVQ2 or above, this does not meet the minimum standard of 50 of staff with a NVQ2. However it is recognised that as doing the NVQ is mandatory for all staff at this home, this should ensure that the minimum number of staff required to have a NVQ is either always well met or in the process of being met. The following requirement is however currently necessary: 50 of staff must have an NVQ2 qualification. The home has an induction programme but this did not appear to be as detailed as those that meet sector skills council specifications and targets. For example the induction within 6 weeks followed by foundation training, with all tied into the relevant NVQ. The following requirement is therefore set: The home must demonstrate how its induction programme meets sector skills council specifications and targets, or use a system that does. Staff recruitment documents were examined and these included CRB checks, references and proof of identification. However some references were missing. 3 out of the 4 staff files sampled did not contain references. The following requirement is now therefore set: Staff references must be held on file and made available at inspections. Supervision records were not up to date and did not meet the minimum of 6 sessions per year. Some staff records only showed 2 supervision sessions in 2007. Even if these had occurred, records of these are required to be kept and kept securely. The following requirement is therefore now set: All supervision sessions must be recorded and occur at least 6 times per year. These shortfalls under this staffing standard are not of serious concern in themselves, but combined are of some concern and have a greater impact on the outcome for this whole group of standards. The Eadmund DS0000067667.V343944.R01.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): Standards 37, 39, and 42: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a generally well run home and the current manager has the required qualifications and experience. The home’s quality assurance system involves the residents, but needs to provide feedback to them, to allow them to be involved in improvements and measure improvements in the home for themselves. The home generally promotes the health and safety of the residents, so that practices and the environment do not place their health and safety at risk The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 23 EVIDENCE: The current manager has the required NVQ 4 Registered Manager’s award and is suitably experienced to manage the home with over 10 years management experience in this field. There is a quality assurance system, which includes the complaints system, service user meetings, provider inspection visits, user satisfaction surveys. There is however no annual development plan to tie this together and provide a document which can provide feedback to service users and allow them monitor progress in implementation of issues raised. The last key inspection report therefore contained the following recommendation under Standard 39: An annual development plan should be produced and once the quality assurance system has been completed for this financial year, the relevant results and any following action points should be recorded in this document. This had not been implemented by the time of this inspection and the recommendation therefore remains. This was made a recommendation as opposed to a requirement as the home was new at the time of the last inspection and it would have been unreasonable to set a requirement when the home had not been operating long enough to go through the annual cycle of a quality assurance system. By the next key inspection, enough time would have elapsed to expect a quality assurance system to be in place. This recommendation will therefore be converted to a requirement at that time, if it remains unmet. All of the health and safety policies and procedures relevant to this standard were seen to be present. Moving and Handling, Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. The testing of systems required in Standard 42 were also present and inspected. These included fire fighting equipment testing, fire warning testing, Portable Appliance Testing, 5-year wiring testing and Bacterial analysis and testing of the water supply. The Eadmund DS0000067667.V343944.R01.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 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 x x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 Requirement Care plans must contain all the elements of need required under Standard 6, and record guidance how to meet them. Risk assessments must be produced where any restrictions of liberty or pre-planned restraints are assessed as necessary for the protection of service users { e.g. locked kitchen and front door}.These risk assessments must also contain details of how training and other options have been explored, and the involvement of relatives or independent advocates. The home must demonstrate how its induction programme meets sector skills council specifications and targets or use a system that does. 50 of staff must have an NVQ2 qualification. Staff references must be held on file and made available at inspections. All supervision sessions must be recorded and occur at least 6 times per year. DS0000067667.V343944.R01.S.doc Timescale for action 01/06/08 2. YA9 17[1]a 13[7] 01/06/08 3. YA35 18[1]c 01/06/08 4. 5 6 YA32 YA34 YA36 18[1]a 17 18[2] 01/06/08 01/04/08 01/06/08 The Eadmund Version 5.2 Page 26 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 YA39 Good Practice Recommendations An annual development plan should be produced and once the quality assurance system has been completed for this financial year, the relevant results and any following action points should be recorded in this document. The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 The Eadmund DS0000067667.V343944.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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