Inspection on 06/12/06 for Vicarage Road (1&3)

This inspection was carried out on 6th December 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Vicarage Road (1&3) 07/01/08

Vicarage Road (1&3) 21/09/05

Vicarage Road (1&3) 05/08/05

Vicarage Road (1&3) 22/02/05

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 Vicarage Road (1&3) 1&3 Vicarage Road Dagenham RM10 9SX Lead Inspector Joanna Moore Key Unannounced Inspection 6th December 2006 09:30 DS0000060786.V323028.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 DS0000060786.V323028.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. DS0000060786.V323028.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Vicarage Road (1&3) Address 1&3 Vicarage Road Dagenham RM10 9SX 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) 020 8592 8734 The Avenues Trust Limited Janet Frances Kedgley Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places DS0000060786.V323028.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2005 Brief Description of the Service: 1 to 3 Vicarage Road is a newly purpose built 8 bedded unit comprising of two connected bungalows set on a housing development. The home is registered to provide care for service users with learning disabilities and/or physical disabilities and current residents have very high care needs, staff use their knowledge of service users means of communication to effectively understand their needs as the range of verbal communication that service users are able to use is limited. All but one of the current service users previously resided in Little Highwood Hospital, a long stay institution due for closure. The home is operated by Avenues Trust, which is a registered Charity. All the bedrooms are en-suite, there are two large dining/sitting areas, two kitchens, two laundrys and two garden areas. The home also has its own custom built vehicle, which staff drive to take service users out on outings. At the time of the inspection there was one vacancy. DS0000060786.V323028.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the annual inspection plan. The inspector toured the buildings, spent time with service users and staff, met with the Community Learning disabilities Nurse and examined records. An Inspection by the CSCI Pharmacist inspector had been carried out the previous day and their findings are also included in this report. What the service does well: What has improved since the last inspection? The home has worked hard to address all the requirements from the previous inspection. The inspector was pleased to see improvements to the acre planning and staff supervision systems. DS0000060786.V323028.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. DS0000060786.V323028.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 DS0000060786.V323028.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): 1,2,3,4 &5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are enabled to have as much understanding about coming to live in their new home as is possible. Service users need are fully assessed before admission and a trial stay “test drives” the home to make sure it will meet their needs. EVIDENCE: No new service users have been admitted to or discharged from the home since the last inspection. It was noted at the last inspection that there were contractual issues, which undermined all the national minimum standards in relation to a specific admission. The inspector is satisfied that the Organisation will ensure clear agreements are in place for all future admissions. All service users have had a full multi disciplinary assessment before moving into the home to ensure the home is able to meet their needs. A trial stay is also in place for all prospective service users to ensure that in practice the home is able to meet their needs and aspirations. Due to the care characteristics of service users the organisation used advocates to support the moving in process. Contracts are in place however these have only been signed by the organisation It is required that the organisation look at how this information can be shared with service users and their representatives most usefully. DS0000060786.V323028.R01.S.doc Version 5.2 Page 9 Information about the home is available in a service users guide. DS0000060786.V323028.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9&10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from staff and resources, which are committed to enabling them to have a varied lifestyle and to gain a fuller understanding of the world around them. EVIDENCE: In every bedroom and lounge throughout the building there was evidence of work ongoing to enable service users to have a fuller understanding of their world and what was happening. This was achieved through the provision of sensory materials on the walls and activities within the home. The Inspector examined three service users care plans. These comprised of a pen picture of the service user, communication methods, medication requirements, personal care needs, continence management and sleeping patterns. A daily record is written in a diary. DS0000060786.V323028.R01.S.doc Version 5.2 Page 11 Each service user has a key worker linked with the Person Centred Planning process. All the service users have very limited verbal communication skills but are able indicate through individual communication methods such as pointing or using behaviour to express their preferences. None of the service users undertake activities that necessitate any limiting of decision making. Service users the inspector was informed were being encouraged to learn how to make basic choices within their lives which is for some a new skill. Staffing levels are high due to the care needs of the service users and therefore staff are on most occasions able to support the individuals expressed wishes at any given time. Service users life plans included photos of them being involved in the development of these documents. The care plans were useful documents and included specific means of communication, which helped the inspector very much during the inspection. For example one service user will approach people and sit by them, which means he wants reassurance and his neck stroking, it has to be borne in mind that this is one of the only ways of communicating that this person has which says “ I want company”. Care plans had been reviewed and updated. Staff were aware of confidentiality and all files were held securely. A confidentiality policy was in place and discussed with staff during the previous induction process. DS0000060786.V323028.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16&17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users within their care characteristics are offered various opportunities to gain a greater understanding of their home and wider community through the provision of activities both inside and outside of the home. Service users are provided with a suitable, varied and nutritious diet. EVIDENCE: Care records and care plans evidenced individualised care thorough noting each person’s specific methods of communication and what they mean. Care records also recorded preferences for times for getting up and going to bed and these varied between individuals. Activities, which had taken place for those people whose files, were viewed included bowling, going to the shops, trips to the pub and restaurants, beauty sessions, canal boat trips, and day trips to the seaside in the summer. All DS0000060786.V323028.R01.S.doc Version 5.2 Page 13 service users have the opportunity of a one week holiday however where this is not thought to be beneficial for the service user a series of day trips are arranged instead. Service users make use of the taxi card scheme. In house activities supplement these and a variety of sensory equipment is available including bubble machine and ball interaction. Service users have specific dietary needs some due to swallowing difficulties. These needs are documented in their care plans and are known to staff. Food is specifically cooked to provide a soft diet to all service users. Contact with families varies according to family wishes. The home however endeavours to maintain and improve on family contact. One service user has regular visits from their sister; another is taken by the home fortnightly to visit their mother who is in a nursing home. One service user whose family lived a substantial distance away was preparing to travel with staff to visit their mum and take up Christmas presents. The organizations quality questionnaires included comments from relatives to the effect that they were made to feel welcome when visiting and that the home was very good at letting them know what had been happening in their loved ones lives. The Inspector saw a number of risk assessments carried out on activities such as moving and handling, choking, swimming, using the kitchen, shopping and use of wheel chairs in the community. DS0000060786.V323028.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18- 21. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive support from all appropriate professionals to ensure that their healthcare needs are met. Personal care is provided in a way, which meets their needs and accords dignity. The home fails to protect service users through robust systems to ensure the safe storage and administration of medication. EVIDENCE: Staff use their knowledge of the service users communication and preferences to provide personal care in a way, which is in line both with the service users needs and preferences. All the service users need total personal care. All personal care is given in their own room or bathroom. Service users are encouraged to give what personal care they can to themselves but this is very limited. There is no rush to be up at a particular time so staff try to ensure DS0000060786.V323028.R01.S.doc Version 5.2 Page 15 there is one to one time with the service user when getting them ready for the day. Service users are encouraged to express preferences for what they wish to wear. Support is received from the local Community Learning Disability Team and the home is able to contact them for advice and support on any aspect of the service users care. The Community nurse said that they were very confident that the home refers issues appropriately to the nursing team. Staff then follow recommendations through as guided. The home regularly liaises with the consultant Psychiatrist and implements monitoring charts for behaviour and epilepsy. “The staff at the home are very caring they are also polite and make me feel welcome. I have no concerns at all about the care. In fact I have seen such improvements in the service users since they came in their skin condition, flexibility and strength and their psychological well-being and behaviour.” Service users are also supported by other relevant professionals such as the district nurse, GP, dietician, epilepsy nurse, psychologist, Occupational therapist and speech therapist. One service user had been admitted to hospital on a number of occasions due to increased epileptic seizures and staff visited the individual every day for long periods of time. A document recording the families’ wishes in the event of the service users death has been developed in partnership with an advocate. The pharmacist inspector visited the day before this inspection at the request of the inspector. The home had between may and October four separate incidents which have sometimes involved a group of residents, where staff have either failed to give the medication, given incorrect doses or given it to the wrong person. The Pharmacist inspector has written a separate report to the home but a summary of the issues of concern noted were as follows: Medicine administration record (MAR) chart entries are required for each prescribed dose of each medicine that is prescribed for regular administration. Six examples where this requirement was not met were indicated to the home’s senior care worker in charge at the time of the inspection where blank entries require investigation to determine whether or not the doses were given to the service users. The corporate medicines policy was amended in October this year and it is recommended that the home implement this, together with any agreed adaptations for local variation, as soon as possible. This should avoid the current need to file separate documents with the medicine administration record (MAR) charts to supplement the home’s current medicines policies & procedures as this may be confusing and they could be lost or overlooked. Lyn Colsey for Avenues Trust informed the home that the Trust is in the process of preparing the document for distributing to the homes. It is recommended that the prescribing of lactulose on a when required basis for service users (SU) be DS0000060786.V323028.R01.S.doc Version 5.2 Page 16 reviewed by their GP. The mode of action of this laxative normally requires 2 to 3 days for therapeutic effect and is therefore unsuitable for intermittent use. Prescribing for constipation should be reviewed and if a laxative is still required on a when required basis, either with or without regular administration of lactulose according to individual service user requirements, then a stimulant or mixed action laxative may provide more effective therapy, e.g. magnesium hydroxide mixture or senna. It is required that the home meet those requirements set by the Pharmacist. DS0000060786.V323028.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. The organisation had effective complaints and adult protection policies in place to respond to any concerns and to protect service users. Service users finances were safeguarded. EVIDENCE: No complaints had been received since the last inspection. One compliment was recorded which said: “A is very fortunate to be living in such a lovely environment with people who really care around them”. The home has an appropriate complaints procedure in place, which is available in both pictorial and DVD formats and is displayed in the hallway. Service users may make their dissatisfaction known, however due to their care characteristics would find it very difficult to effectively formally complain. No formal advocates are involved with service users at present. The inspector was advised that advocates had been involved in the process of service users moving in and preparing the ‘in the event of my death’ care plan and that their services could be purchased on an individual case by case basis should the need arise. Staff are trained in Adult Protection. The home had the appropriate Local Authority’s Adult Protection policy in place and a whistle blowing policy. DS0000060786.V323028.R01.S.doc Version 5.2 Page 18 The Registered Manager is Appointee for all the service users. All service users’ benefits are paid directly into their bank accounts and their rent deducted from these accounts as well. Any spending undertaken by staff on service user’s behalf has to be counter signed by the Registered Manager. Two service users finances were checked, there was a record, which showed money taken out of the bank account and transferred to the personal saving account, and spending could be evidenced via receipts. Systems are now in place for recording any group expenditure such as holidays. Service users finances are audited on a rolling program as part of the monthly visits carried out by the representative of the registered person. A full audit is planned for January the inspector was advised. DS0000060786.V323028.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. 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 benefited from a safe, well maintained, decorated and furnished home which met their needs. EVIDENCE: The home is a newly built purpose designed home. All bedrooms are single, wheelchair accessible, have en-suite facilities and ceiling hoists. All bedrooms were individually decorated and furnished and held items of individual interest. One service users room had a wide variety of sensory equipment, which they enjoy using another service user liked big cats and had lots of pictures and soft toys of Lions etc. All bedrooms are lockable and provided with magnetic door closures linked to the alarm system. There is plenty of communal space with large dining/ sitting rooms decorated and furnished in a homely manner. There are plenty of toilets and shower rooms in the building with additional specialised bathrooms. There are also separate laundry facilities. The premises are maintained by a housing association. Aids and adaptations required by DS0000060786.V323028.R01.S.doc Version 5.2 Page 20 service users had been assessed by an Occupational Therapist prior to the service users moving in. The home was well equipped to meet the service users needs through the provision of overhead and mobile hoists, grab rails and specialist beds. The home does not have dedicated cleaning staff. Care staff as part of their duties undertake cleaning. Disposable gloves and aprons were provided to minimise the risk of infection when providing intimate personal care. The home was clean and tidy on the day of the inspection. The gardens had been developed in the last year to provide more interesting and sensory experiences for the service users. DS0000060786.V323028.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31-36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from high levels of staff that are caring and competent. Staff benefit from appropriate training and support. Staff recruitment in the main protects service users from unsuitable people gaining employment but one requirement has been made. EVIDENCE: A clear management structure is in place both in the organisation as a whole and within the home. Staff job descriptions were at a previous inspection noted to be clear and as no changes had been made these were not viewed at this inspection. Staff were familiar as to their roles and responsibilities. The inspector was advised that the organisation is restructuring staffing with homes and Vicarage Road will benefit from a new deputy post. Staffing levels within the home are high and reflect the needs of service users. On the day of the inspection staff were deployed on a 1:1 basis, the staffing rota confirmed this to be the norm. Without the current levels of staffing service users would undoubtedly have far fewer opportunities to access the DS0000060786.V323028.R01.S.doc Version 5.2 Page 22 community. The home is to be commended on providing staffing levels, which enable service users to have such a full and varied lifestyle. All staff appointments were subject to a probationary period and from then on staff receive an annual appraisal. A clear induction program was in place, which covered key areas of the organisation including policies and procedures and human resource issues as well as health and safety and client care. However of the three completed inductions which the inspector requested one was not available as it was with the employee. 14 staff were in post, of these 5 had completed NVQ level 2 in care and 3 had completed level3. the home is therefore meeting the 50 ratio of NVQ qualified staff. Staff files viewed evidenced staff receiving training in First Aid, Administration of Medication, Management of Aggression, Understanding Challenging Behaviour, fire, manual handling, food hygiene and infection control, health and safety, valuing diversity, report writing, record keeping, adult protection, de-escalation and diffusion techniques and introduction to learning disabilities. Staff meetings were recorded as happening regularly. Staff individual supervisions were taking place at least six times per year. Staffing records required were not available at the home as the inspector chose new staff and the recording systems had not been updated. The staffing records requested however were brought to the CSCI office by the regional manager in agreement with the inspector. The staffing files evidenced clear and robust systems for the recruitment of staff including checks on identity, criminal records checks, medical check and Two written references were available. Details of the staffs’ employment history was sought but there was no evidence that this went back further than 2002. The registered person is required to ensure that a full employment history covering the last 10 years is obtained and any gaps explored. It is recommended that ability to work in the UK be clearly recorded as checked. DS0000060786.V323028.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37-43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and staff benefit from clear leadership from the manager and organisation as a whole. Service users are protected by clear and accurate recordkeeping and policies and procedures. The health and safety of service users and staff are protected. EVIDENCE: The pre-inspection questionnaire outlines clear systems for monitoring health and safety within the building. No issues of concern were noted when touring the building. Fire records evidenced regular testing and maintenance of fire equipment. On checking records it was not absolutely clear whether a current gas safety certificate is in place. Staff assured the inspector that a gas check DS0000060786.V323028.R01.S.doc Version 5.2 Page 24 had been carried out but this could not be evidenced. The registered person is required to ensure a current gas safety certificate is in place. From observation during the inspection of interaction between service users and staff and from the comments received from the learning disability nurse the inspector is satisfied that the home is run in the best interests of those people living there. An annual survey is sent to relatives to give feedback on what they think of the service and a selection of their comments are included in this report. The manager was registered and assessed by the Commission to be a fit person to manage the home. Ms Kedgley has over 20 years experience in working with people with learning disabilities and previous to this role held the role of deputy manager. Ms Kedgley has completed her NVQ level 4 in care and Registered Managers Award. Statutory records were held appropriately either accessible or confidential according to the type of record. Records viewed included the visitors’ book, complaints record, staffing rota, staff recruitment, service user assessments, care plans and daily records, finances, accidents and regulation 26 visits. Records as a whole were satisfactory and kept up-to-date unless detailed in the specific section relating to the record. The difficulty with records was that it was very difficult for staff to lay their hands on the records when asked for them. There was much confusion as to where things were, a staff had gone home with a key leaving records, which should be accessible, not accessible. The lack of clear filing and systems for records management effectively caused much delay during the inspection and added stress and frustration for staff and the inspector. In other circumstances these difficulties could have resulted in the home receiving many more requirements and recommendations that eventually were given due to being unable to evidence things that had in fact been done. It is strongly recommended that a review of the records management within the home be undertaken. The home is one of a number run by Avenues and there was no information to suggest that the home was not financially viable. Appropriate insurance was in place in relation to employers, public, and products liability in addition to professional indemnity. DS0000060786.V323028.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 2 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 3 3 3 3 3 2 3 2 DS0000060786.V323028.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA5 Regulation 5 Requirement It is required that the organisation look at how the contract of residence can be shared with service users and their representatives most usefully. It is required that the home meet those requirements set by the Pharmacist. The registered person is required to ensure that a full employment history covering the last 10 years is obtained and any gaps explored. The registered person is required to ensure a current gas safety certificate is in place. Timescale for action 01/04/07 2 3 YA20 YA34 13 17 22/12/06 01/01/07 4 YA43 23 01/01/07 DS0000060786.V323028.R01.S.doc Version 5.2 Page 27 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 YA34 YA41 Good Practice Recommendations It is recommended that ability to work in the UK be clearly recorded as checked. It is strongly recommended that a review of the records management within the home be undertaken. DS0000060786.V323028.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 DS0000060786.V323028.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!