Inspection on 28/02/06 for The Old Forge

This inspection was carried out on 28th February 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Old Forge 26/02/09

The Old Forge 19/03/07

The Old Forge 25/08/04

The Old Forge 06/04/04

The Old Forge 06/08/03

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 The Old Forge Mill Road Slapton Bucks LU7 9BT Lead Inspector Mrs Maureen Richards Unannounced Inspection 28th February 2006 09:30 The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Old Forge Address Mill Road Slapton Bucks LU7 9BT 01525 221506/7 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) Turnstone Support Ltd Yok Lin Chong Care Home 4 Category(ies) of Learning disability (4) registration, with number of places The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 2005 Brief Description of the Service: The Old Forge is a small care home that is registered to provide care and accommodation to four service users with learning disabilities. The home is administrated by Turnstone Support Housing Association and is one of several homes in Buckinghamshire that is registered under the auspices of the Commission for Social Care Inspection.The Old Forge is situated in the village of Slapton, close to the border of Bedfordshire. The home is centrally situated in the village, close to the local amenities. The nearby towns of Leighton Buzzard, Aylesbury and Milton Keynes provide the service users with a wide range of amenities. Access to the towns is via the home’s own transport.The Old Forge is a single storey building, which has been sympathetically refurbished to meet the needs of service users. There is a car park at the front of the property with spaces for approximately four or five vehicles. At the rear of the property there are enclosed communal gardens. The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of the Old Forge took place over five and a half hours on the 28th February 2006. The inspection consisted of discussions with the registered manager, individual discussions with two staff, introduction to the service users, a tour of the environment and examining records. The majority of the key standards were inspected at the previous unannounced inspection. The purpose of this inspection was to reassess some of the key standards, assess the remaining key standards and to follow up on the progress made in meeting the requirements from the previous inspection. All of the requirements from the previous unannounced inspection have been complied with. Four comment cards were received from relatives who indicated they were happy with the care provided. One comment card from a relative identified some areas for improvement, which is referred to within the report. Two service user comment cards were received from the advocate involved with the home completed on behalf of the service users. These indicated the service users were happy with the care provided. Two comment cards were received from health professionals who were happy with the care provided. One health professional commented, “that the service users receive A1 care”. What the service does well: What has improved since the last inspection? What they could do better: The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 6 Service user plans must be further developed to include the level of support required by individuals in managing their finances. If foot massages are required they must be carried out by suitably qualified staff. Service user plans should accurately reflect the actual practice in relation to foot massages. Service users involvement in activities of daily living must be further explored and developed to promote and develop service users independence. The manager must ensure that service users are called by their preferred form of address. The manager must ensure that all staff have medication administration assessments carried out and maintained up to date. The organisation should ensure that safe administration of medication refresher training is made available to staff. A copy of the complaints procedure should be made available to relatives. The damp patch in a service users bedroom and smell of damp in the shower room must be addressed. Areas of the home must be decorated and worn and damaged items of furniture must be repaired and or replaced. A programme of redecoration and renewal of equipment should be available at the home. The manager must ensure that staff left in charge of the home are 21 years of age and confirmation of the required recruitment checks must be available in the home for sessional workers prior to them working a shift at the home. Specific risk assessments must be put in place to safeguard service users. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The key standard was assessed and met at the previous unannounced inspection. There have been no new admissions to the home during this time. The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 The home has detailed support and lifestyle plans in place which require further development to ensure that staff are consistent in promoting service users independence. Up to date risk assessments are in place, which promotes service users safety and well being. EVIDENCE: One service user plan was viewed at this inspection. Two service users were out of the home and the staff were unable to obtain permission to view their service user plans, the other service user refused to give permission to view his plan. The service user plan seen contained a personal details information sheet, a photograph and pen picture of the individual, which outlined the individual’s likes and dislikes. It contained communication information guidance, which was implemented in 2004 but did not show evidence of being reviewed and updated since that date. The service user plan contained a number of support plans in supporting the service user to become involved in aspects of his care and life at the home. All of the support plans were dated, signed by staff and included a note to indicate The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 10 it was discussed with the service user but the service user was unable to sign. Each of the support plans included a progress record. The manager confirmed that the progress record is meant to be completed each time the service user is involved in that specific task. One of the progress records was not updated to indicate progress or involvement in that specific task since January. Some of the progress records indicated that “there was no change as previous” which did not give an accurate record of the service users involvement in the task and would make the review of the progress with this task difficult to assess. The service user plan included essential lifestyle plans, which outlined the level of support & involvement required in household tasks, choosing meals. personal care, support with post, medication, and healthcare needs. The organisation has developed value based practice guidance regarding independence and choice in managing finances. Service user plans did not make reference to the level of support and involvement required by individuals in managing their finances. This must be included. The service user plan includes a record of activities and daily contact sheet. The activities record and daily contact sheet indicates that staff carry out foot massages. The manager confirmed that staff are not trained in massage and do not carry out massages. Instead they offer the service user a foot spa and cream his feet. The records must accurately reflect the practice. The manager confirmed that the service user plans are in the process of being updated to a standard format by the organisation and this is required to be in place for all service users by June 2006. Service user plans included a series of risk assessments with an assessment tool to identify the hazards and a risk assessment, which indicates the level of risk posed and a management plan to manage the risk. The risk assessments on the service user plan seen was signed by the keyworker and manager and indicated discussion with the service user. It was up to date and included a review date. Service user plans included moving and handling assessments, which were reviewed and up to date. The home has a missing persons procedure in place, which includes notification to the Commission. The home has a separate folder with personal details and photograph of each service user, which would be used by staff to give to the police in the event of a service user going missing. The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standards were fully assessed at this inspection. All of the key standards were inspected and met at the previous unannounced inspection. At the previous inspection the manager confirmed she had applied on behalf of two service users to reinstate access to day centres. At a recent review it was agreed to make more use of community resources for individuals as opposed to day centres attendance. The progress with this will be reviewed at the next inspection. At the previous inspection the manager confirmed that she was in the process of making enquires about service users joining the Gateway Club in Leighton Buzzard. This has not progressed. During the inspection two service users went out with two staff to an activity and one service user had one to one input at the home from a member of the Connect team. The other service user sat in his wheelchair dozing occasionally playing a peg board game by himself. One staff member commented that she felt there should be more activities on offer and opportunities for service The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 12 users to go to day centres One comment card received from a relative / visitor commented that they were concerned that the service users are not receiving enough stimulation. When they have visited the home there have been opportunities to involve the service user in everyday activities for example having a part in cooking their dinner with little indication of this happening. During this inspection one service user sat in the kitchen with the staff member whilst they were preparing lunch and making pancakes. Staff were observed making drinks for service users as opposed to involving the service users in the activity. The manager must discuss this feedback with the staff team to look at ways of further promoting service users independence and involvement in activities of daily living. During the inspection it was noted that staff abbreviated one service user’s name. This individual’s pen picture included in the service user plan did not make reference to this abbreviation of his name. The manager should ensure that staff use service users preferred form of address. The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Medication at the home is well managed despite the lack of pre printed medication administration records being provided. This promotes the safety and well being of service users. EVIDENCE: Standard 18 was not assessed. However one comment card received from a relative / visitor commented that there were few communication tools evident and this was very important in giving service users the opportunity to communicate and to aid their understanding. The manager confirmed that she felt there were communication aids available for individuals as required for example prompt cards and pictures. One service user is registered blind and the manager confirmed that the intention is to contact the RNIB to access appropriate aids for this individual. This standard will be fully assessed at the next inspection. None of the service users are self-medicating. Service users plans outline the rationale behind this decision. All medication prescribed for service users is dispensed at the dispensary, which is attached to the general practice in Edlesborough and are delivered to the home on a weekly basis in dosette boxes. The dispensary do not supply pre printed medication administration records. The manager has had to develop printed medication administration records for their use in the absence of printed medication administration The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 14 records being supplied by the pharmacy. The manager has requested pre printed medication administration records but to no avail. She has requested a move of GP surgery, which has been declined. The manager should access a copy of the Royal Pharmaceutical guidelines on administration of medicines in care homes to ensure that this practice is in line with the guidance. The home keeps a record of medication ordered, received and disposed of. The current system of printing medication administration records and the receipt of medication is time consuming. The manager feels she has to retain responsibility for this which makes it difficult if she is going on annual leave. The medication is stored in a locked cupboard in the office and excess and as required stock are stored in a locked cupboard in the laundry room. Some service users are on as required medication and guidance is in place to indicate when and why this medication should be administered. The medication administration records showed no gaps in the administration of medication and a record is maintained to indicate why a medication was not administered. Despite the absence of pre printed medication administration records the medication is well managed. The manager confirmed that all staff are assessed and deemed competent prior to being expected to administer medication. Generally two staff are involved in the administration of medication but a written procedure is in place to address the situation of only one staff member having to take responsibility for medication administration. Staff medication assessment records seen indicate that some staff are overdue for medication assessments. The manager confirmed that staff have training in safe handling of medication. The training records do not indicate the frequency of this training and some staff last had this training in 2003. This should be addressed. The home has a medication policy in place, which is dated 2000 and does not include a review date. The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the above standard were assessed. The key standards were assessed and met at the previous unannounced inspection. The home has had no complaints since the previous unannounced inspection. Some relatives indicated on the comment cards that they did not know how to make a complaint. The manager should consider sending a copy of the complaints procedure to all relatives to address this. The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 16 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 Areas of the home are in need of redecorating and items of furniture need to be replaced to ensure that service users live in a homely, comfortable and safe environment. EVIDENCE: The Old Forge is a single storey building, which has been refurbished and adapted to meet the service users needs. The home has a ramp and handrail to enable the service users to access the building and handrails are situated internally in the toilets, bathrooms and along the corridor. Service users have their own bedrooms, which were decorated and furnished to their tastes prior to them moving in. All of the bedrooms are very individual and include personal possessions. All of the bedrooms have a handbasin. A requirement was made at the previous inspections that the water damage in one of the bedrooms requires repair. This had been repaired but is in need of further attention. This area appears damp and when touched the plaster was loose and coming away. The home has one bathroom with a toilet, turntable and an assisted bath with an overhead shower. The home has a separate shower room and toilet and a further single toilet. The shower room felt cold and smelt musty and damp. This should be addressed. The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 17 There is a communal lounge / diner, separate kitchen and separate laundry room. The suite in the lounge appeared shabby and the arms are stained. The legs of the dining table are badly scratched and the decoration in this area is below standard with splatters of paint from the wall on the skirting boards. A requirement was made at the previous unannounced inspection that the worktop adjacent to the sink in the kitchen requires replacement. This has not been replaced but has been repaired with a white tile. Some of the kitchen cupboards were noted to be falling down off their hinges. This must be addressed The walls of the corridors and doors are badly scratched by the wheelchair. The manager confirmed that the organisation is looking at addressing this and putting a protective layer at the bottom of the door and walls as required. The manager confirmed that no redecoration has taken place since the home opened. This is evident in the home’s general appearance. The manager confirmed that she has identified with her manager areas of the home to be redecorated and items to be replaced as part of the new financial year. There is no programme of planned maintenance and renewal at the home to support this. Standard 30 was not assessed at this inspection. This standard was assessed at the previous unannounced inspection. A requirement was made at the previous unannounced inspection to repair or replace the lock to the COSHH cupboard in the laundry room. This has been complied with. The home appeared generally clean however it was noted that the windows were in need of cleaning and there were cobwebs on the inside of the office window. The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, & 36 Specialist training and NVQ training is made available to staff which ensures that services users are supported by trained and competent staff. Adequate staffing levels are maintained to meet service users needs, however on occasions staff left in charge of the home are not 21 years of age, which could compromise service users safety. Confirmation of recruitment checks for sessional workers is not available at the home, which potentially put service users at risk. Staff feel supported and are supervised in their role, which benefits service users. EVIDENCE: Staff were observed to be accessible to and comfortable with service users. They appear to have developed a good understanding of service users individual communication needs. Some staff have had Learning Disability Award Framework training and specialist training in positive communication, epilepsy, diversity awareness and deafness awareness training. The manager confirmed that five support workers have achieved an NVQ and a further two staff are scheduled to commence this training. The home has developed professional relationships with other professions and feedback from two health The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 19 professionals supports this. The comment card received from the local GP surgery commented, “that this home offered A1 care” At the time of this inspection the home had a full time senior carer and support worker vacancy. Attempts were being made to recruit in to those vacancies. A staff member was being transferred from another service on a temporary basis to assist in the senior role. The rota seen indicated two staff on each day time shift with the manager as the third person on shift to ensure that there are sufficient staff to take service users to planned activities. At night there is a waking night staff and a sleep in person. Staff are responsible for the cooking and cleaning and the manager and senior provide back up on call support. The home uses sessional workers to cover vacancies and shifts as required and has three sessional workers on their books that they use on a regular basis. The manager confirmed that they have no staff under 18 years of age. During the inspection it was established that the home has one support worker under 21 years of age. This individual works alongside sessional and permanent staff. The permanent member of staff is in charge of a shift when working with sessional or agency workers. The manager must ensure that this individual is not left in charge of the home. Staff confirmed that they have regular team meetings and minutes of meetings confirm that team meetings take place monthly. Three staff files were viewed at this inspection. The staff files seen contained a copy of the application form, appointment letter, job description, confirmation of medical clearance, copies of two references and confirmation of CRB clearance. Files contained copies of birth and marriage certificates, copies of passport and driving licence. None of the staff files contained an up to date photograph of the staff members. One staff member had recently returned to work part time. A revised contract was not on file to support this. Files for the sessional workers were requested but were not available at the home. The manager had no confirmation that the schedule 2 information had been obtained for those individuals. The manager must ensure that the sessional workers do not work unsupervised with service users until such time as she has obtained written confirmation that the required checks have been carried out. Schedule 2 information should be maintained for sessional workers who work at the home on a regular basis and a summary of those checks is acceptable for all other sessional workers on the organisation’s list who may work at the home on an occasional basis. This must be addressed immediately to ensure the protection and safety of service users. Standard 35 was not fully assessed. This standard was assessed and met at the previous unannounced inspection. Training records seen indicate that some staff including the manager are overdue for updates in some safe working practice training. The manager has identified this and has put staff names forward to go on the next available training courses. The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 20 The manager confirmed that she supervises all staff. The senior would be expected to assist in the supervision of care staff. Supervision records are maintained of supervision sessions. Staff confirmed that they receive regular supervision and feel supported in their roles. The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 21 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 The home has had the continuity of a manager, which has provided service users with stability in the move into the community. EVIDENCE: The manager confirmed that she had obtained an NVQ level 4 qualification in management. She is a qualified nurse and has worked at the home as the registered manager since the home opened. The manager has been proactive in meeting requirements from the previous inspection. The certificate of registration and liability insurance was displayed in the office. The manager confirmed that she attends relevant training and records indicate that some mandatory training is now overdue. The manager appears to have worked with staff in ensuring continuity for service users in the transition from hospital to the community. This now needs to be developed to promote further service users involvement and independence within the home. Staff confirmed that they feel the home is well managed and the manager is approachable and supportive to them in their roles. The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 22 Standard 42 was not assessed at this inspection. This standard was assessed and met at the previous unannounced inspection. During the tour of the home it was noted that latex gloves are left out in the bathrooms. Individual service users risk assessment must be put in place to indicate that access to latex gloves does not put service users at risk. One service user has a cot side on his bed on the side nearest the wall. The service user tends to lie on that side and the manager confirmed that this is to prevent the service user from resting against the wall. A risk assessment must be put in place to confirm that the use of cot sides does not pose any risks to the service user. The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 2 1 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Old Forge Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X X X DS0000028058.V262578.R01.S.doc Version 5.0 Page 24 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 YA6 Regulation 15 Requirement Service user plans must outline the level of support required by individuals in managing their finances to promote their involvement and develop their independence. Service users plans must reflect the actual practice in relation to massaging service users legs. If staff are required to massage service users legs then appropriate training must be accessed. The manager must ensure that opportunities are made available and utilised to promote service users independence and involvement in activities of daily living. The manager must ensure that all staff medication administration assessments are kept up to date. The damp patch on the wall of one service users bedroom must be further investigated and made good. The smell of damp in the shower room must be addressed. Areas of the home must be decorated to an acceptable DS0000028058.V262578.R01.S.doc Timescale for action 30/04/06 2 YA6 12 31/03/06 3 YA16 12 30/05/06 4 YA20 13 30/04/06 5 YA24 23 10/04/06 6 YA24 23 30/06/06 The Old Forge Version 5.0 Page 25 7 8 YA33 YA34 18 19 9 YA42 13 standard and worn and damaged items of furniture must be repaired and or replaced. The manager must ensure that staff left in charge of the home are at least aged 21. The manager must ensure that sessional workers do not work unsupervised with service users at the home until such time as schedule 2 information has been obtained. Risk assessments must be put in place to indicate that the use of cot sides and access to latex gloves does not pose risks to service users. 28/02/06 17/03/06 31/03/06 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 Refer to Standard YA16 YA20 Good Practice Recommendations The manager should ensure that staff use service users preferred form of address and service user plans should make reference to preferences. The organisation should agree the frequency of safe administration of medication training and ensure that all staff have up to date safe administration of medication training. The manager should consider sending a copy of the complaints procedure to relatives of service users. The home should have available a planned programme for redecoration of areas of the home and of renewal of furniture and soft furnishings. 3 4 YA22 YA24 The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Old Forge DS0000028058.V262578.R01.S.doc Version 5.0 Page 27 - 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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