Inspection on 31/05/06 for Thicket Road

This inspection was carried out on 31st May 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Thicket Road 15/12/09

Thicket Road 15/08/07

Thicket Road 03/01/06

Thicket Road 18/05/05

Thicket Road 19/10/04

Thicket Road 30/04/04

Thicket Road 21/12/03

Thicket Road 14/08/03

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 Thicket Road 79 Thicket Road Penge London SE20 8DS Lead Inspector Miss Rosemary Blenkinsopp Key Unannounced Inspection 31st May 2006 10:00 Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 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 Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 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. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thicket Road Address 79 Thicket Road Penge London SE20 8DS 0208 776 9569 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) www.leonard-cheshire.org.uk Leonard Cheshire Ms Susan Cornish Care Home 7 Category(ies) of Learning disability (7), Physical disability (1) registration, with number of places Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 03/01/06 Brief Description of the Service: The home is a seven-bedded facility for those residents with a learning disability including one person with a physical disability. The residents in this home have challenging behaviour and need structured behaviour programmes with on-going support. Staff are provided throughout the 24-hour period with waking night staff. The home is a large detached house in a residential area of Penge. It is well served by public transport and close to local amenities. The home has undergone major refurbishment including a two-bedded extension on the lower ground floor. This has significantly improved the home for residents and staff. Policies, procedures and documentation are generated through Leonard Cheshire Foundation with amendments made locally. The fees in this home range between £1,200 and £1969.83 weekly. The report will be made available in a pictorial format, as other documents have already prepared in this format. Staff will spend time going through the elements of the report with residents and facilitate a level of understanding as far as their abilities allow. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted unannounced by one inspector and one Regulation Manager. The pre-inspection questionnaire was not received prior to the inspection therefore the comment cards from care managers, next of kin, GP, the multi disciplinary team, and the residents themselves, were not received prior to the site visit. These were posted after the site visit. Two residents were case tracked as part of the site visit. The case tracking included viewing of the individuals’ care plans and supporting documentation with periods observing resident’s support, as far as this was possible, and meeting their key workers. Other key standards were inspected including, health and safety, staff recruitment and training. A limited tour of the home was undertaken and generally found to have significantly improved. The residents with whom the inspectors met had more interaction than on previous visits. There were some good improvements noted in communication with several of the residents and signs of well being evident. This is a significant move forward. What the service does well: What has improved since the last inspection? Since the last inspection several training opportunities have been provided for staff including the LDAF, which is specifically relevant to learning disability services. One staff member has also undertaken training in risk management. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 6 Residents were, in the main, much more settled and they engaged more with the staff and between themselves. Some residents communicated with the inspectors, albeit on a more limited level. One resident has obtained paid employment which is a great achievement for both the resident and the staff in the home. This is to be commended. Senior staff are now on every shift to direct the staff team. On call support is covered by the three senior staff in the home, this provides a good management framework. 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. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 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 Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 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. The quality relating in this section is adequate. This is based on all information provided including the site visit. Assessment information made available, was limited in content and it would be difficult for staff to obtain enough information to meet the residents’ needs. EVIDENCE: The information relating to the assessment of the last admission was viewed. Leonard Cheshire has a standard assessment tool which was completed. The format was tick box with comments in a separate column. The detail on this form was limited with some of the elements having little specific information completed. The residents in this home have complex needs and detailed information regarding these is needed, so that staff can base a plan of care. There was other information in the file relating to the resident’s finances, activities of daily living and some of her behavioural problems. There was a detailed assessment from Bromley Social Services. The resident had had several trial visits prior to her permanent placement. It was difficult to extract the information in respect of these visits, or the reviews conducted after the initial trial period, which is usually three months. It would be at the threemonth review that the decision regarding permanent placement would be confirmed using all available information. The home must, following its assessment, confirm in writing to the resident its ability to meet all their needs. Terms and Conditions and Individual Service Agreements were available. Please see Requirement 1. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 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): 6,7,9. The quality relating in this section is poor. This is based on all information provided including the site visit. The care plan documentation was limited in content, review dates and relevant intervention information. Risk assessments were similarly completed. Reviews were overdue. EVIDENCE: Two care plans were inspected of those residents who were case tracked. The files were cumbersome and it was difficult to extract information from them. Several items contained within them were out of date and should be removed for archiving. The care plan information was in various formats; some presented in the form of guidelines, others in standard support information. Some of the guidelines were very detailed. One, in respect of bathing a resident, was very comprehensive and in a narrative format. Other issues set out on a standard support plan were poor and did not give sufficient detail of the interventions needed. This resident had mental health issues, which again were limited in their inclusion in the care plan. Information was, however, available in other formats in respect of mental health problems, although difficult to extract from the file. The care plan had been generated in March 2004. This resident had Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 10 significantly changed in the two years since this care plan had been implemented and therefore it should have been fully reviewed to reflect her current situation. There were monthly summaries covering activities of daily living included in the care plans, although the last one available was dated January 2006, and prior to this there were gaps evident between July 2005 and December 2005. The risk assessments for this resident included road safety, finances and an eating disorder generated 2002 and 2003. These were limited in content and the information included would not fully address the risk. The reviews were also overdue, some not reviewed since May 2004. The Manager stated that assessments were conducted and recorded on separate sheets although during the site visit these could not be located. The second care plan was similarly completed. In general care plans were in need of review as were risk assessments. Current information from the multi-disciplinary teams was not easily accessible including the annual reviews. All care plans should be audited to ensure that information is readily available, current and the files themselves maintained in an orderly manner. Residents are enabled to be involved in the decision making process as far as they are able. Makaton signs for several documents have been produced, including the Service User Agreement, and more are due to be developed. Staff assist residents, with involvement in care planning where possible, which includes choices in individual activities. Please see requirements 2 and 3. Please see Recommendation 1. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 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): 12,13,15,16,17. The quality relating in this section is good. This is based on all information provided including the site visit. Residents are provided with opportunities to experience a varied lifestyle whilst living in the community. Residents are supported with employment and leisure activities available within their community. EVIDENCE: Residents are supported in all leisure activities including those in the community. One resident has recently obtained paid employment, which is a significant achievement not only for the resident but also for the staff involved in this process. This resident, along with one other, attends college. This is to be commended. Each resident has a specific daily programme, which includes attendance to day centres, household chores and social activities. Residents are supported to use public transport – on resident enjoys trips to the centre of London. Residents are supported with holidays and days out. There is a holiday planned to Bognor Regis this summer. During the course of the inspection residents Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 12 were seen to come and go undertaking various activities. Visiting is open – some residents do spend time at home, usually weekends. Meals are prepared by staff within the home. Healthy eating is encouraged. A selection of foodstuffs was seen to be available including fresh fruit and vegetables. Within each residents care notes is a daily food intake list. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 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): 18,19,20 The quality rating in this section is good. This is based on all information provided including the site visit. Health care is accessed through the local community with staff support. Residents are able to access all health care in the local area except where specialist services are required. The documentation relating to medication was reasonably well completed. EVIDENCE: Within the case files there was information relating to health care appointments. Those records seen, included information from dental, opticial and the GP. All residents, except one, are supported to attend the GP surgeries as part of normalisation and involvement with the local community. The records relating to GP attendance were documented on separate sheets. Specialist services are provided through the Bassett’s Centre which offers support from the multi disciplinary team. Dental services are provided through Guys and Bassett’s Centre. Records relating to accidents and other incidents were available. Any resident requiring hospital treatment would have an incident form/accident form completed. Staff attend first aid training and on almost every shift, there is a person who has completed the four-day first aid course including one night staff. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 14 The medication cupboard was found to be tidy and secure. The home operates the Boots medication system. Currently there are no residents who self medicate. The medication charts had the allergies omitted on several charts. Records of medications received, and those returned, were in place. Those medications, which are administered as required, need to have full instructions indicated including maximum dose, reason for administration and duration where applicable. One chart was particularly untidy where information and instructions had been changed. Information must be clearly documented, any changes should have two staff signatures to confirm the amendment so that there is no margin for error. Please see Requirement 4. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The quality rating in this section is adequate. This is based on the information received including the site visit. Staff are aware of adult abuse and whistle blowing procedures. Complaints information is available although more resident friendly formats need to be devised. EVIDENCE: The CSCI have received no complaints regarding this service since the last inspection. Complaints information is available in the hall although this format is unsuitable for the residents in this home and useful only for relatives or visitors. The staff training list indicated that most staff receive training in protection of vulnerable adults every two years. In addition, complaints and whistle blowing training are addressed on a regular basis. One staff member who works on the bank for three days a week was aware of what abuse constitutes and how to report this internally, although had little knowledge of the external bodies. The staff member had not received specific training in this topic and the training records indicated this was the case. Please see Recommendation 2. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 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): 24,30 The quality relating in this section is good. This is based on all information provided including the site visit. The environment is homelike and has ongoing maintenance as the behaviour of residents causes a lot of damage. It is suitable for the current residents who live in the home although, without adaptations and amendments to the steep front stairs, this will, with the ageing population, not always be the case. EVIDENCE: A tour of the home was undertaken including the lower ground floor areas. Some of the bedrooms were inspected but not all. Generally the standard of the environment had significantly improved. Communal areas were maintained in a homely manner. The flooring in the dining room was uneven underfoot this should be investigated and addressed. There is an ongoing refurbishment programme underway and the next area due for refurbishment is the top floor bathroom. The bathroom, which was recently refurbished, to a high specification vandal proof standard, is maintained in keeping for a domestic house. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 17 The bedrooms were much tidier, hazard free and personalised. Residents in this home may take many years to adapt to any change be it minor, so the fact that one resident had now allowed photographs and two prints in his room, is a reflection of the ongoing positive strides made with residents in the home. The lower ground floor has been well maintained, except the carpet needs shampooing. The laundry area was unlocked as were the cupboards, which contained some COSHH substances, however staff were in the vicinity although not in the actual area. COSHH substances need to be securely stored. Two areas which need to be addressed, are the kitchen flooring which had become stained and the stair carpet. A deep clean of all surfaces and paintwork should be undertaken. Please see Requirement 5. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 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): 32,34,35 The quality rating in this section is adequate. This is based on all information provided including the site visit. Staff are provided in sufficient numbers to meet the current needs of the residents group. The recruitment of new staff needs is insufficiently robust to protect residents with confirmation of checks not evidenced in those files inspected. EVIDENCE: There are seven staff on duty throughout the home in the morning and five during the afternoon period. Senior staff are always on duty with on call support. This has improved the management of the home. Between the hours of 7am and 8 am, two staff are on duty until the full compliment of day staff arrive. This situation must be kept under review to reflect residents’ needs and staff increased if necessary. Currently the home has four vacancies, which are covered by bank and agency staff. Recruitment into this service has proved difficult. The inspector met with one bank staff who confirmed that she always had senior support on duty with her. She had received induction and had a good knowledge of the residents for whom she was caring. The inspector viewed the induction checklists in use for agency staff, which included , checking of the photographic identity and qualifications for all new staff. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 19 A permanent staff who was a key worker to one of the residents case tracked, also demonstrated a good knowledge of the resident, his family network and the support that he requires. Staff with whom the inspector met related variable comments in respect of working within the home and the changes that had taken place in the last year. One staff member felt that the lines of communication with management were not always receptive to staff issues. The inspector checked the staff member’s personnel file and within it was evidence of supervision, which included discussion regarding her work and training needs. Three staff personnel files were considered at the time of the inspection. The quality and consistency of the information when employing care staff requires attention. Evidence of incomplete application forms, lack of POVA/CRB checks and inconsistent referencing was apparent. Human Resources information had been received via two corporate locations, which detracts from the ‘ownership’ of a process, which relies on consistent attention to detail and the need for compliance with the amended Regulations to the Act 2004. LDAF training is underway, three staff have completed the introduction, two the foundation training, however, five staff have not yet completed this. Two staff have completed the NVQ level 2. A selection of training records indicated mandatory training and additional topics including first aid, POVA, whistle blowing etc. Each staff member has training itemised on their individual supervision sessions and a list of planned training was provided. All staff need to have the mandatory topics addressed at the stated intervals and training relating to residents needs provided. Items such as abuse and whistle blowing should be at regular intervals to keep staff abreast of changes. Please see Requirements 6 and 7. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 20 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 The quality rating in this section is adequate. This is based on all of the information including a site visit. The management of the home has been strengthened to offer greater support to staff and residents in the home. The home has ongoing maintenance and servicing of equipment although not all of the certificates were available. EVIDENCE: The manager has been in post for some time having previously worked in the home as part of the support team. She receives ongoing input advice and support from senior Leonard Cheshire personnel. She has completed the Registered Managers Award as a well as a number of other management related topics. Fire procedures are in place but require some up-dating so that every member of staff who comes on duty is made aware of what to do in the event of a fire. This is the overall responsibility of the shift leader who has to ensure everyone is out of the building. The procedure needs to be consolidated indicating clearly what is expected of each staff member. Fire drills need to be carried out at Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 21 more regular intervals, the last one was dated 8.2.06. Fire alarm testing is carried out weekly but fire extinguishers were overdue for service checking. All permanent staff attend fire awareness training. Fire exits were clearly signed, there are two means of exit at Ground Floor and Basement levels. The Registered Manager established at time of inspection, that fire equipment was due to be serviced on 7.6.06. Bedroom doors on the first and second floors require checking as some of them appear to have excessive gaps at the bottom which may assist the seepage of smoke into some residents’ rooms in the event of a fire. The inspectors were advised that the Providers Health and Safety Officer was visiting the premises, also on 7.6.06. The inspectors were advised that all staff had moving and handling training and basic one day first aid training, with the designated ‘First Aider’ receiving the more comprehensive four day training course. Other training such as the “fire marshal” course and “ COSHH risk assessor” training had been undertaken by staff members. Residents’ risk assessments are currently kept in one main file; staff are apprised of risk assessments on induction. The Manager is due to go on a risk assessment course shortly. One Team Leader has already attended this training. It has been proposed that new risk assessment procedures will be put in place to provide more comprehensive robust information to staff. The inspector recommended that risk assessments are placed into individual resident files to ensure consistency of care and easy access to information for all staff, including bank and agency. It is recommended that staff should then sign off that they have read and seen the care plan including risk assessments for each resident. The gas certificate was in place as well as evidence of other service certificates. Lifting equipment had been serviced March 06. Certificates for the electrical hard wiring five-year service, and PAT testing were unable to be located. Confirmation that these have been addressed needs to be forwarded to the CSCI. Regulation 26 visits are conducted and reports forwarded to the CSCI. Staff meetings are held two weekly. Regular staff supervision was evidence efrom staff themselves and personnel files. The Manager is looking into an external person to facilitate the residents meetings. The home is currently undergoing Investors in People scheme. Please see requirement 8. Please see recommendation 3. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 22 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 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 2 X 3 X 3 X X 2 X Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 23 Yes 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 YA2 Regulation 14 Requirement The Registered Manager must ensure that full assessment information is available and confirm in writing, following their own assessment, the home’s ability to meet their needs. The Registered Manager must ensure that full assessment information is available and confirm in writing, following their own assessment, the home’s ability to meet their needs. The Registered Manager must ensure that care plans are comprehensive in content, kept under review and have all supporting information easily accessible and available. The Registered Manager must ensure that risk assessments are in place for all residents, specific to needs, kept under review dated and signed. Previous time frame for action 30/01/06. This is now outstanding. Timescale for action 31/08/06 1a YA3 14 31/08/06 2 YA6 15 31/08/06 3. YA9 13 31/08/06 Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 24 4 YA20 13 The Registered Manager must ensure that all information relating to medication is recorded and charts are maintained in an orderly manner to reduce the margin for error. The Registered Manager must ensure that all areas are maintained in a safe and hazard free manner. The Registered Manager must ensure that all staff are subject to robust recruitment procedures which can be evidenced. This is now outstanding previous time frame for action 30/03/06. The Registered Manager must ensure that all staff, including agency workers, are suitably trained for the work that they do. This is now outstanding previous time frame for action 30/6/05. The Registered Person must ensure that all health and safety issues are addressed including servicing of equipment, staff training and maintenance of the environment. 31/08/06 5 YA30 23 31/08/06 6 YA34 19 31/08/06 7. YA35 18 31/08/06 8. YA42 13 31/08/06 Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 25 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. Refer to Standard YA7 YA22 YA35 Good Practice Recommendations The Registered Manager should ensure that all documentation is maintained in an orderly manner and current. The Registered Manager should explore methods of communication appropriate to the resident group. The Registered Manager should ensure that all training received by staff is signed including all documentation, risk assessments and care plans. Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Thicket Road DS0000006968.V293390.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!