Inspection on 22/11/06 for Three Gates

This inspection was carried out on 22nd November 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 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Three Gates 12/01/06

Three Gates 25/07/05

Three Gates 16/03/05

Three Gates 19/08/04

Three Gates 03/02/04

Three Gates 15/05/03

Three Gates 26/11/02

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

CARE HOME ADULTS 18-65 Three Gates (Amber Project) 62 Cloves Hill Morley Derbyshire DE7 6DH Lead Inspector Tony Barker Key Unannounced Inspection 22nd November 2006 09:20 Three Gates DS0000020109.V320092.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 Three Gates DS0000020109.V320092.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. Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Three Gates Address (Amber Project) 62 Cloves Hill Morley Derbyshire DE7 6DH (01332) 880584 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.unitedresponse.org.uk United Response Caroline Lee Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: Three Gates is a detached bungalow in a rural position on the edge of a village. Service users are provided with spacious accommodation and single rooms. There is a large rear garden. Three Gates offers personal and social care to people with a severe learning disability with associated conditions that may include autism, sensory disability or challenging behaviour. Activities are planned to meet individual needs, and service users experience a wide range of community-based activities. The fees currently range from £965 to £1421 per week. Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 8 hours and was a key unannounced inspection. The service users had high levels of dependency and therefore were not able to contribute directly to the inspection process, though they were observed working with and being cared for by staff. The Manager and one senior support worker were spoken to and records were inspected. There was also a tour of the premises. One service user was case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The preinspection questionnaire was reviewed prior to this inspection. What the service does well: What has improved since the last inspection? Staff had helped each service user to understand the Home’s service users’ guide and a copy had been placed in each individual’s file. Aspects of the Home’s record keeping had improved. The premises had been decorated throughout and new windows had been fitted. Maintenance had improved and there was a more homely appearance. Infection control practices had improved and the cleaning materials cupboard had been made secure. Staff training records were relatively up to date and fire training sessions were being provided at a greater frequency. The allocation of management hours to the Home had increased. Three Gates DS0000020109.V320092.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 summary of this inspection report can be made available in other formats on request. Three Gates DS0000020109.V320092.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 Three Gates DS0000020109.V320092.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users had the information they needed to make an informed choice about where to live and their individual needs were assessed so that staff could provide individually tailored care. Each service user had an individual written contract with United Response, setting out their terms and conditions of residence. EVIDENCE: The Home’s service users’ guide was personalised to the Home. The Manager said that staff had helped each service user to understand the service users’ guide and a copy was then placed in each individual file. There had been no new admissions to the Home since the inspection in April 2004 when the Inspector found standard 2 fully met. The contract between each service user and United Response was personalised to the Home and each service user had been supplied with a copy. It had staff photos but needed to be updated to reflect recent management changes. The contract contained simple ‘Picture Bank’ pictures to aid service users’ understanding of the document. The Manager said that ‘widget’ symbols would be added to further improve service users’ understanding. Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users were not always benefiting from the care planning system as it did not reflect their full range of needs. They were making decisions about their lives, with assistance, and were being supported to take risks to improve their independence. EVIDENCE: There were a range of useful documents, relating to each service user, on their individual file. The file relating to the case tracked service user was examined in detail. This included several Life Skills Forms that incorporated goals for staff to achieve. The Manager was aware that these Forms were not worded in a ‘person-centred’ way – that is, from the personal perspective of each service user. She said that staff were currently attending ‘Person Centred Planning’ training days provided by Derbyshire Social Services. Also a document called ‘Listen to Me Workbook’ was being considered. This includes the individual’s ‘likes and dislikes’, ‘hopes and dreams’ and ‘changes I’d like to make’. Once this document is completed, and in use, it should provide a holistic, ‘personcentred’ approach to care planning. Currently, the Home’s documentation was not holistic in that it did not reflect the action that needs to be taken by staff to Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 Page 10 ensure that all aspects of each service user’s health, personal and social care needs are met. The individual service user files were in addition to a folder for Medicine Records and one for Daily Logs. These logs did not reflect any care planning goals – which would help to evaluate the achievement of these goals. Also, there was limited evidence of any assessment of service users’ response to activities. The Manager showed the Inspector a proposed ‘learning log’ that took a ‘person-centred’ approach. These two folders were for daily use by staff and the individual files were used mainly as a filing system, the Manager said. She spoke of working towards having four ‘working files’ that would include current care plans, risk assessments and daily logs. This would mean staff having easy access to current care planning documents that would guide them to provide individually tailored care. It was noted that individual service user records had been kept reviewed and up-dated. However, many records had not been dated or signed. The senior support worker, who was spoken to, gave examples of service users making decisions and choices with staff assistance. She said that two options of clothes to wear are offered to service users if they make inappropriate choices due to the weather, for example. She pointed out that usually they make their own choices of clothes to wear. During the inspection one service user was observed to be signing their wish to go out and another their wish to go out and have a beer. Staff responded appropriately to these requests. Good use was being made of symbols around the Home, to enable service users to communicate their wishes. Care plans included a record of service users’ likes and dislikes, both written and in widget (symbol) form. Service users’ files contained a range of recorded risk assessments and some of these contained a section headed, ‘What are the benefits from taking the risk?’ This showed that staff were being encouraged to support service users to take responsible risks. The senior support worker confirmed this by reflecting on the danger from traffic when service users go out walking and the risks involved when service users make a cup of tea. These activities enable service users to develop their skills and confidence in daily living. Most risk assessments were being reviewed periodically. Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were involved in fulfilling and age-appropriate activities in the Home and in the local community. They were able to maintain appropriate family relationships, where available, and were provided with a healthy personalised diet. Daily routines reflected their individual choice and promoted independence. EVIDENCE: None of the service users were attending formal education though they were all involved in some form of day service – three at external services and one from the Home. The senior support worker was able to provide evidence of service users being involved in valued and fulfilling activities. This evidence included service users’ positive mood and pride in craft items, made at day services, displayed in their bedrooms. The senior support worker added that one service user particularly enjoys chopping up vegetables – an activity that this service user initiates without prompting. Service users were regular users of local facilities, the senior support worker confirmed. She said that they went to local shops, pubs, restaurants and a Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 Page 12 garden centre. One service user enjoyed planting out the items bought at the garden centre – using troughs and compost and watering the plants afterwards. The pre-inspection questionnaire, completed by the Manager, included other activities in the community that included horse riding, swimming and the library. The case tracked service user’s file included a list of ‘known places’ that included shops, pubs and walks. Three of the service users had varying degrees of contact with relatives. The fourth had a close relationship with an ex-member of staff from an establishment previously lived in. There was contact from other ex-staff from that establishment with all these service users and friendships with other exservice users from that establishment were being re-established. The senior support worker gave examples of how service users’ involvement in daily routines reinforced their personal development. They clean their bedrooms on their ‘personal day’ at the Home and the case tracked service user enjoys washing the Home’s mini-bus on Sundays. Staff recognise this enjoyment through positive noises from the service user, the senior support worker said. The Home had a five-week rolling menu that indicated that service users were being provided with a varied and nutritious diet. The menu was also based on service users’ individual preferences and included weekly ‘theme night’ items. The senior support worker said that a nutritionist had approved the Home’s menu in the past. She added that all service users were involved in food preparation and food shopping. Food stocks were found to be at a satisfactory level and these included fresh fruit and vegetables. The evening meal was observed, with four service users and two care staff sitting at the dining table in a relaxed manner. Good-sized portions of food were seen and service users seemed to be enjoying their food. The case tracked service user had a pie instead of the fish eaten by the others. This was the service user’s choice, staff said. Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were receiving personal support in the way they preferred and required. Their health needs were being met and they were generally being protected by the Home’s procedures for dealing with medicines. EVIDENCE: The senior support worker gave examples of how staff meet service users’ privacy needs by, for example, knocking on doors before entering and service users being encouraged to wear a dressing gown on the way to the bathroom. She gave further examples of how routines are flexible to meet service users’ individual needs and circumstances. She said that the case tracked service user enjoys walking and may request to go out although this may not be planned. Staff will oblige if at all possible, she said. The senior support worker spoke of her satisfaction working with the four service users, saying, ”I connect with them...we communicate...I get to know what they want”. Each service user had a ‘communication board’ displayed on the wall outside their bedrooms. These boards gave a pictorial indication of the current day’s activities. The Manager provided sound verbal evidence of staff supporting service users to maximise their independence. One service user, for example, has developed self confidence at a local pub to the point where she now orders Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 Page 14 a drink independently of staff and the bar person offers her a choice of bottles. The Manager also showed how this service user’s activities reflect personal lifestyle preferences. However, there was little evidence on records of staff supporting service users to maximise their independence. Each service user’s medical appointments and contacts were being recorded on Report Feedback sheets. One of these contacts was with a district nurse following serious sun-burn to one service user’s shoulder while on holiday. Appropriate measures were taken immediately following the incident and to prevent this happening again. Also, a good set of records were made. One service user’s file had no Medical Profile, as at the previous inspection. The Manager said that all files would have an updated Medical Profile soon. There was evidence on files of involvement of a range of external health professionals. Service users’ Medication Administration Record (MAR) sheets were examined and found to be satisfactory. It was noted that there was now a record of staff signatures/initials with the medicine records to ensure that signatures can be cross-referenced against staff names. Medicines were securely stored. There were no written policies in place to explicitly detail the circumstances of service users needing ‘prn’ (when required) medication administered and the maximum dose in a 24-hour period. Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were benefiting from the Home’s complaints policy and procedures and were being protected from abuse. EVIDENCE: The Home’s complaints procedure was displayed in the hallway. It had been improved by the use of widgets (symbols) that could be better understood by service users. The Manager said there had been no complaints made within the previous 12 months. She added that ex-members of staff, from an establishment service users had previously lived in, attended care plan review meetings and acted as advocates for service users. The complaints file was set out in a satisfactory manner. The Home had an extensive written policy and procedure on prevention of abuse linked to the statutory procedures and prepared by United Response. However, it was still not clear that the Social Services Department should be the first point of contact, unless an incident of a serious nature warrants urgent referral to a doctor or to the police. The Manager said that all staff had attended United Response adult abuse training. She was planning to attend ‘Safeguarding Adults’ training provided by Derbyshire Social Services. There was a robust system of recording cash withdrawn by service users with their cash cards as well as a monitoring sheet regarding all aspects of personal finance. Balances were checked twice daily, the Manager said. The case tracked service user’s recorded money balance was cross-referenced against cash held and found to be accurate. Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were living in a comfortable and safe environment that was clean and hygienic. EVIDENCE: The premises had been decorated throughout since the previous inspection and new windows had been fitted. The seat to the WC in the shower room had been replaced and the striplights in the lounge had been replaced with light fittings of a more domestic appearance. The dining room had rather bare walls and the benefits of placing some wall pictures in this room, and in corridors, was discussed with the Manager. She spoke of plans to hang canvasses, painted by the services users, in the dining room. The level of lighting in the shower room was low although the Manager said this room was not used. The bathroom was bright and attractive and the bedrooms were well personalised. The lounge was comfortable. The standard of decoration and furnishings throughout the premises was high. There was a large spa bath in the rear garden that had been well used by service users, the Manager said. From the tour of the premises there was evidence of good standards of cleanliness and hygiene throughout the Home with no unpleasant odours. Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 Page 17 Staff on duty and service users carried out household cleaning duties at the Home, the latter dependent on capability. The Home had an industrial-type washing machine and dryer which were appropriate for the service users’ needs. The laundry was kept locked when not in use. An infection control risk assessment was seen and this now addressed the issue of moving infected material around the Home. The Manager said that soiled bedding is brought to the laundry room in appropriate bags - an improvement on the practice noted at the previous inspection. The senior support worker confirmed that these improvements had taken place. One service user brings their own personal underwear to the laundry room and places it in a basket. Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 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. 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 this service. Service users were being supported by a well-trained staff group and protected by the Home’s recruitment procedures. EVIDENCE: 50 of the care staff had achieved a National Vocational Qualification (NVQ) to level 2 or above. This met the National Minimum Standard to maintain a staff group with at least 50 qualified staff. The Manager said that two further staff were due to achieve this qualification by April 2007. Discussion with the senior support worker gave opportunity for an appraisal to be made of the quality of, at least, this member of staff. She was found to be sensitive, insightful and with a positive outlook – having the interests of service users very much at heart. There were three periods during the week when three members of staff were on duty to enable social outings to take place. Otherwise there were two staff on duty except for one hour on Wednesday afternoons when there was just one staff member with two service users. The Manager said there was a recorded risk assessment on lone working although this did not refer to any maximum travel time for an additional member of staff to arrive if called out in Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 Page 19 an emergency. Staff meetings were taking place every three weeks. Other aspects of Standard 33 were not assessed on this occasion. The file of a member of care staff appointed in March 2006 was examined. It was found to contain all but one of the elements, required by current Regulations, regarding recruitment practices. There was no reason given why the person had ceased to work with vulnerable adults in two previous care assistant posts. It was noted that United response usually follow good staff recruitment practices. There was evidence of this same member of staff being provided with induction training to Learning Disability Award Framework (LDAF) standards, as recommended by Standard 35. Training records showed that all staff had been provided with all mandatory training and the pre-inspection questionnaire detailed a number of other courses undertaken, or to be undertaken, by staff that addressed the individual needs of service users. The senior support worker confirmed she had been provided with a number of training courses over the previous 12 months. Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users were benefiting from a well run home and their health and safety was being promoted. They were not benefiting from an effective quality assurance system, where views of service users and other stakeholders were taken account of. EVIDENCE: The Manager had achieved her National Vocational Qualification (NVQ) in Care at level 4 and was anticipating completing the Registered Manager Award training course in March 2007. She had just become a credited trainer. She had worked with people with learning disabilities for 6.5 years. Her hours were split over the two homes she manages, as agreed with the Commission, and she said her post was now additional to the staffing establishment. There was now a full time Senior Support Worker with Additional Responsibilities at the Home and this has meant an improvement in management time allocated to the Home. Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 Page 21 Monthly independent audit visits to the Home on behalf of the Registered Provider, as required by Regulation 26, were not taking place. The Manager said that United Response was only planning an independent audit every year. The Home’s annual ‘Action Plan’ was examined. This was usefully holistic with objectives and target dates. No quality assurance questionnaires were in use, in order to assess opinions on the quality of service provided by the Home. However, the Manager said that draft questionnaires were being sent to service users, advocates and relatives. No questionnaires were planned to be sent to staff or external professionals, who would have a view on the Home. Good food hygiene practices were noted and the kitchen was clean and tidy. Safe storage of cleaning materials was observed. Weekly fire alarm tests were recorded as well as monthly fire drills – with night time fire drills being held every six months. The Manager said that there were written risk assessments for the Home’s environment. The pre-inspection questionnaire, completed by the Manager, indicated that equipment in the Home was being maintained and good Health and Safety practices followed. There was still no exterior lighting to the area where the garage is situated and where staff have to access a freezer. There were no other Health and Safety problems identified. Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 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 YA6 Regulation 15(1) Requirement Service users’ care plans must be holistic covering all aspects of personal, social and healthcare needs. (This was a previous requirement) Where a person has previously worked in a position which involved contact with vulnerable adults, written verification of the reason why the person ceased to work in that position must be given. Monthly independent audit visits to the Home on behalf of the Registered Provider, as required by Regulation 26, must take place. The registered person must formally seek the views of service users, family, friends and others involved in the service users’ lives regarding the quality of service provided. (This Timescale for action 01/04/07 2. YA34 19 Schedule 2 01/01/07 3. YA39 26 01/01/07 4. YA39 24(1) 01/04/07 Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 Page 24 was a previous requirement) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA5 Good Practice Recommendations The registered person should consider improving the contract between each service user and United Response, as detailed in this report. (This was a previous recommendation) A person-centred approach should be taken to the Home’s care planning documentation. All records should be dated and signed. Daily logs should reflect care planning goals. Individual service users’ files should be reviewed to ensure consistent documentation is in place. (This was a previous recommendation) Written policies should be in place to explicitly detail the circumstances of service users needing ‘prn’ (when required) medication administered and the maximum dose in a 24-hour period. The Home’s written policy and procedure on prevention of abuse should make it clear that the Social Services Department should be the first point of contact, in the event of suspicion of abuse, unless an incident of a serious nature warrants urgent referral to a doctor or to the police. (This was a previous recommendation) The Manager should attend ‘Safeguarding Adults’ training provided by Derbyshire Social Services. The recorded risk assessment on lone working for staff should include reference to a maximum travel time for an additional member of staff to arrive if called out in an emergency. The registered person should review the standards of exterior lighting around the Home. (This was a previous requirement) 2. 3. 4. 5. 6. YA6 YA6 YA6 YA18 YA19 YA20 7. YA23 8. 9. YA23 YA33 10. YA42 Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Three Gates DS0000020109.V320092.R01.S.doc Version 5.2 Page 26 - 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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