Inspection on 24/10/06 for The Knole

This inspection was carried out on 24th October 2006.

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 Knole 19/11/08

The Knole 12/11/07

The Knole 09/01/06

The Knole 26/09/05

The Knole 10/03/05

The Knole 06/09/04

The Knole 25/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

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

CARE HOME ADULTS 18-65 The Knole 23 Griffiths Avenue St Mark`s Cheltenham Glos GL51 7BE Lead Inspector Mr Adam Parker Key Unannounced Inspection 24th October 2006 10:00 The Knole DS0000016612.V313528.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 Knole DS0000016612.V313528.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 Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Knole Address 23 Griffiths Avenue St Mark`s Cheltenham Glos GL51 7BE 01242 526978 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) knole@langleyhousetrust.org www.langleyhousetrust.org The Langley House Trust Mr Malcolm James Gardiner Care Home 9 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (9), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (7) The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be over 30 years of age. All Persons accommodated will be male. Date of last inspection 9th January 2006 Brief Description of the Service: The Knole is a care home operating within Christian principals that provides registered accommodation for up to nine males who have mental health needs. Four places are registered for learning disabilities and up to seven for service users over 65 years of age. The home is a detached Victorian listed building situated in extensive grounds approximately one mile from the centre of Cheltenham. It has recently undergone major renovation. Current fees are £827.22 per week paid by placing authorities. Chiropody and personal toiletries are charged extra. The home makes information about the service, including CSCI reports available to service users through a service user guide and statement of purpose available in the home. The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The visit to the service included a tour of the premises, examination of documentation and discussions with a service user, staff and management. As well as a visit to the service over two days, comment cards were received from a General Practitioner (GP), six service users and nine members of staff. What the service does well: What has improved since the last inspection? The environment of the home has undergone a major renovation with improvements to bedrooms and communal space. Any maintenance or health and safety issues are identified and action taken to ensure they are put right. Risk assessments are provided for each service user. The registered manager continues to work to improve communication with staff and to monitor requests for training needs. Risk assessments are completed for all service users and care plan files were generally in good order. The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Service users receive comprehensive assessments involving a number of agencies to ensure that their needs can be met before they are admitted to the home. EVIDENCE: The pre admission documentation for the service user most recently admitted to the home was examined. Full information about the service user was obtained and this included a comprehensive assessment completed prior to admission into the home in conjunction with other agencies and relevant professionals. This is in line with the type of service offered by the home and relevant documentation had been obtained. In addition to this the home had completed an assessment of the needs of the service user. Any restrictions on freedom based on risk were fully documented in the assessment and had been discussed with the service user. When they arrive in the home service users undergo an induction that is documented on a checklist. The home does not admit service users who are self-funding. The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 9 The Knole DS0000016612.V313528.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. With one exception it was found service users are regularly and actively consulted about their care plans to ensure that their needs and personal goals are met. Service users are actively supported by staff to make decisions about their lives within any limitations set by the nature of the service. Service users have thorough risk assessments although in one case it was not clear how a service user was being protected from a known risk. EVIDENCE: The care plan documentation for one service user recently admitted to the home was looked at. This gave evidence of key working meetings that were taking place on a fortnightly basis where the service user could discuss with their key worker how they were making progress in meeting goals set in the care plans. The inspector was told that a full review of the care plan takes placeevery six months with a review every three months. However The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 11 examination of another service user’s care plan showed that a care plan review form had been partially completed in February 2006. This document was not complete and gave no information about the actual care plan review. The last key working session for this service user had been completed in June 2006; the registered manager explained that this was due to the more stable situation with this service user. The documentation for a third service user was looked at and in this case the last care plan review involving a meeting with the service user had been completed in early October 2006. There was evidence with two service users receiving input from mental health services that they were aware of the role of the Care Programme Approach (CPA) coordinator. This was documented in the minutes of a meetings contained within their care files. The key working meetings provide an opportunity for service users to make decisions about their lives with assistance and within any limits set by the nature of the service. In one example a service user had been given information on dietary requirements relating to health needs. Monthly residents’ meetings are held where service users have the opportunity to make decisions about issues that affect service users collectively such as trips out of the home. Any limitations on choice are made in line with the nature of the service and the home’s duties and responsibilities. A comprehensive risk assessment is undertaken prior to admission and in conjunction with other agencies. Although in one case a current risk assessment had been completed for a service user who had been the victim of a physical assault although this event was acknowledged in the assessment document there was no information on how the service user would be protected if the event were to reoccur. This situation was confirmed by the service user in a discussion with the inspector. The home has policies and procedures and where necessary individual plans to respond to the unexplained absence of service users. The Knole DS0000016612.V313528.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are able to take part in appropriate activities outside of the home, have links with the local community and pursue a range of leisure interests in order to enhance their lifestyle. Service users are able to maintain links with friends and relatives in line with any limitations set by the nature of the service. Within the limitations of the nature of the service provided service users’ rights and responsibilities are recognised and respected. Service users are given a choice of meals and are able to benefit from the opportunity to do their own cooking. EVIDENCE: There have been attempts to find voluntary work for some of the service users in the home however various issues have prevented this from taking place. The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 13 Two service users have been attending courses at a local college. Evidence was seen of service users pursuing hobbies and interests with model making and keeping cage-birds being popular. In addition several service users worked in the home’s garden cultivating vegetables and making use of the new green house. Staff were observed discussing and encouraging service users with these interests. Service users have a weekly art session making use of the well equipped art room. A visiting tutor facilitates this group and there was plenty of evidence of the service users’ work with painting and threedimensional models. The home organises trips out of the home and this was evident in the minutes of a recent residents meeting. On the first day of the inspection visit a number of service users had gone out to visit a motor museum. One service user spoken to stated that the destination of trips out was chosen by the staff and not the service users. He also stated that some trips involved a lot of walking which was not suitable for him. Service users have some contacts with the local community through links with a local church where some of them attend services. In addition service users make use of local facilities such as shops, cinemas, a gymnasium and swimming baths. One service user had recently received a bus pass enabling him to make more use of public transport. One service user had a friend outside of the home and there were records of regular visits to the friend being made. Other service users had held meetings with relatives and friends who lived in another part of the country and a record had been made of these meetings. Staff were observed knocking on service users doors before entering and this was confirmed by one service user spoken to. In addition service users have keys to the locks for their rooms although these could be entered by staff using a master key in the event of an emergency. Service users mail is logged by staff but delivered to them unopened. Service users have responsibilities for some house keeping tasks and there is a rota for them to do their own laundry. Several service users were keeping cage-birds as pets in their rooms. The home makes clear statements regarding the rules on smoking, alcohol and drugs. Service users were observed having lunch in the new dining room on the second day of the inspection visit. A choice of main dish is provided each day with the cooked lunch. At tea time there is a cooked meal provided. The one service user spoken to was unhappy with some of the meals provided at tea time. However it was noted that this issue had been discussed at a residents’ meeting where alternative dishes had been put forward by service users for consideration. As well as the main kitchen the home has a training kitchen that has been provided following the renovation work. This allows service users to cook their own meals on one day a week and has been a success. Evidence The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 14 was seen of one service user being given advice on dietary needs in relation to a health problem. The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Personal guidance or support is offered to meet service users needs. The health needs of service users are met with the home working in conjunction with health professionals to the benefit of service users. Some improvements need to be made to the medication administration recording systems in the home in the interests of service users’ health. EVIDENCE: The home provides support to service users in terms of guidance with such matters as personal hygiene where this is needed although it does not provide personal care. Service users are allocated to a member of staff who acts as a key worker to provide consistency of support. In one assessment carried out by the funding authority, the service user was noted to be independent in all aspects of personal care. Staff provide support to service users to meet their health care needs for example accompanying them on visits to the GP. There was evidence of liaison The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 16 with a specialist health care professional in relation to the needs of one service user. In addition some service users receive input from mental health professionals. The home provides secure storage for medication and keeps a record of every time the medication cupboard is unlocked. Generally service users do not administer their own medication although some service users take charge of their own inhalers. At the time of the inspection visit the home had no liquid medication, no controlled drugs and no items that needed refrigeration. The medication administration records were examined and there were some omissions from the recording of administration. This included ten occasions when medication prescribed for the control of epilepsy had not been recorded as being administered to the service user. Handwritten directions in the administration charts were generally signed and dated by the person making the entry. A designated member of staff undertakes a monthly audit of the medication administration records. The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home has a policy to prevent abuse and staff have received training, however there have been two incidents where service users have suffered from significant harm and abuse. Service users have access to information about the complaints procedure and several have made use of this to ensure their views are listened to. EVIDENCE: The home has a complaints procedure that is included in the service users guide, given to all service users. The inspector spoke to one service user who had made a complaint. This had been fully documented. However the service user was very unhappy at the outcome of his complaint and felt that there had been a lack of action taken. This was discussed with the registered manager and although some moves had been made to remedy the situation it was to some degree out of the control of the home. Six completed survey forms were received from service users and all confirmed that they knew how to make a complaint. The home has a copy of the Langley House Trust’s policy for the prevention of abuse dated September 2005. However the policy gives no guidance on contacting the Commission in the case of registered services or contacting any local adult protection agencies. Staff receive training to “recognise and respond to abuse and neglect” as part of the basic staff course. However this did not The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 18 include information on the role of outside agencies. A service user was spoken to about an incident where he had been subject to abuse and said he felt there was “No Protection”. There had been another recent incident of abuse in the home and the home had organised a conference to discuss this. The incident had only been reported to the Commission after some delay. The adult protection coordinator from the local authority had not been contacted by the home and confirmed this to the Commission. The delay in reporting the incident to the Commission was noted in the regulation 26 report of the home for 27th September 2006. The registered manager confirmed that in future he would contact the local Adult Protection Unit if any incidents of abuse took place. The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users have the benefit of living in a generally safe, comfortable environment that has recently undergone renovation. The home is maintained in a clean and hygienic state in the interests of service users. EVIDENCE: Since the previous inspection the home has undergone a major renovation and redecoration. There have been changes to bedrooms as well as the communal areas on the ground floor where there is now a new dining room, a new ‘smoking lounge’ and a laundry as well as new staff offices and a kitchen for service users to use to develop cooking skills. All bedrooms in the home are now single occupancy. Two additional toilets and two showers have also been added. The home was generally well maintained with any work required being carried out by the contractors who carried out the renovation work. On the first day of the inspection visit there was a problem with the lock on one service users bedroom door and also a problem with the washbasin. These issues were being The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 20 pursued with the hope of a quick resolution or a temporary change of room was being considered for the service user. The home was clean with handwashing facilities available in toilets. In the laundry there was a small area of the wall where the paint was starting to flake away. This should be attended to before the problem becomes any worse. The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 21 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): 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home’s training programme ensures that service users are supported by appropriately trained and competent staff that generally have developed appropriate attitudes and characteristics. Service users are protected by the home’s robust recruitment practices. EVIDENCE: Staff undergo a basic staff course after starting work in the home. As well as preventing abuse this course includes communication skills, risk assessment, first aid and other subjects and provides underpinning knowledge for NVQ. In addition further training has been undertaken by staff in mental health, medication and dealing with violence. The level of staff trained to NVQ in the home is 80 . Staff were observed interacting with service users and they were approachable and showed genuine interest in the service user’s conversation. This was confirmed by the service user spoken to although there had been one incident where he felt that he had been spoken to in an inappropriate way. Another service user commented on a survey form that “The staff are friendly and helpful” and “ I have always found staff to be helpful if I have any problems.” The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 22 A selection of documentation for recently recruited members of staff was examined and found to be in good order with all the required information about the staff member being obtained. The majority of the information relating to recruitment is held at the head office of the Langley House Trust and is provided to the home on an approved format. This was sufficient to determine if the correct procedures had been followed although it is recommended that information relating to exploring any gaps in employment is more clearly indicated. The registered manager did confirm how this would be explored during the interview. A new member of staff spoken to confirmed that he had only started work after his Criminal Records Bureau check had been received. New staff receive induction training and this was confirmed through surveys received from staff. However one survey indicated that the staff member was unhappy with the induction provided. Another two surveys revealed that staff felt that more training was needed relating to the specific needs of the service users. Supervision records for staff included an area where training issues could be recorded following a discussion. The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from a well run home. The systems for service user consultation in this home are good with a variety of evidence that indicates that service users’ views are sought and acted upon. Training in safe working practices should ensure that the health and safety of service users is promoted and protected although attention still needs to be given to the issue of window restrictors. EVIDENCE: The registered manager has a background in social work and has completed the registered managers award at NVQ level 4 and is an NVQ assessor. He has recently completed training in first aid. Seven out of eight surveys received from staff in the home stated that their manager met with them regularly. The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 24 Over half of the surveys received from staff stated that they had enough support to do their job well. The home has a quality assurance system that where monthly managers reports are produced culminating in a monthly performance report. An example of this was seen relating to accident and incident management in the home. In addition there is an annual service user survey with the results collated for an action plan. There is also a regional residents forum that representatives from service attend and have input into planning and reviewing services. The home also holds monthly residents meetings, the minutes for the most recent meeting showed that service users had asked for a suggestion box to be placed in the home and this was being acted upon. Monthly inspections are made of the home by a visitor and reported to the Commission. Reports of these inspections showed that service users are consulted by the visitor and their views represented in reports. Year on year development for each service user is included in the new licence agreement. The Langley House Trust West area has previously been awarded the Investors in People Award. Staff have received training in safe working practices in first aid, food hygiene, manual handling and fire safety. The home has ensured the serving and maintenance of electrical and central heating systems and appliances. Following the renovation of the home, windows have been fitted with restrictors. However these can be easily removed. Consideration should be given as to how window restrictors could be secured if a risk assessment of a service user indicated the need for this. This issue of window restrictors has been reported in inspection reports prior to the renovation of the home. The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 25 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 X 3 4 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 N/A 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 N/A 3 X 4 X X 2 X The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 26 No 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 (2) (b) Requirement Timescale for action 31/12/06 2. YA9 YA23 13 (4) (c) 3. YA20 13 (2) 4. YA23 37 (1) (e) The registered person shall keep the service user’s plan under review (This relates to the care plan that had not been reviewed in over six months). 31/12/06 The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated (This relates to the risk assessment for one service user who had been the victim of a physical assault where there was no information on how this may be prevented should it reoccur). The registered person shall make 31/12/06 arrangements for the recording, handling, safekeeping,safe administration and disposal of medicines received into the care home (This relates to the instances of lack of recording of the administration of medication to control epilepsy for one service user). The registered person must give 30/11/06 notice to the Commission without delay of the occurrence of any event in the care home DS0000016612.V313528.R01.S.doc Version 5.2 The Knole Page 27 5. YA42 13 (4) (c) which adversely affects the wellbeing or safety of any service user (This relates to the delay in reporting an incident to the Commission). The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated (This relates to the window restrictors and how these could be secured if a risk assessment indicated the need for this). 31/12/06 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. Refer to Standard YA23 YA23 YA23 YA30 YA34 Good Practice Recommendations The prevention of abuse policy and procedure should be updated to include reference to making contact with the Commission and the local Adult Protection Unit. Care Staff should attend the ‘Alerters Guide’ training in adult protection provided by the local Adult Protection Unit. Management should attend the enhanced training in adult protection provided by the local Adult Protection Unit. The flaking paint in the laundry should be attended to. Documentation held in the home relating to individual staff recruitment should indicate where any gaps in employment have been explored. The Knole DS0000016612.V313528.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 The Knole DS0000016612.V313528.R01.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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