Inspection on 10/10/06 for Waymead Short Term Care

This inspection was carried out on 10th October 2006.

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

The inspector found 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Waymead Short Term Care 08/08/07

Waymead Short Term Care 02/05/06

Waymead Short Term Care 07/12/05

Waymead Short Term Care 02/05/05

Waymead Short Term Care 15/12/04

Waymead Short Term Care 27/07/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Waymead Short Term Care St Anthonys Close Off Binfield Road Bracknell Berkshire RG42 2EB Lead Inspector Robert Dawes Unannounced Inspection 10th October 2006 10:30 Waymead Short Term Care DS0000031646.V310393.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 Waymead Short Term Care DS0000031646.V310393.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. Waymead Short Term Care DS0000031646.V310393.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waymead Short Term Care Address St Anthonys Close Off Binfield Road Bracknell Berkshire RG42 2EB 01344 424642 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) Bracknell Forest Borough Council Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Waymead Short Term Care DS0000031646.V310393.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd May 2006 Brief Description of the Service: Waymead Short Term Care Unit provides respite care for adults with a learning disability. The home can accommodate up to 10 service users per night. The home is registered to take service users who are male or female between the ages of 18-65 years. The service is owned and operated by Bracknell Forest Borough Council. Some people are funded by the PCT as their needs are such that they have 100 continuing health care funding, others pay a basic cost of: aged 18-24-£7.20 per night; aged 25—59--£8.90 per night and aged 60 and over--£9.25 per night. After 28 overnight stays in one year service users receive a financial assessment and their contributions are re-assessed. Waymead Short Term Care DS0000031646.V310393.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced site visit which took place during the day and early evening on the 10th October 2006. The Annual Quality Assurance Assessment-Self Assessment, Annual Quality Assurance Dataset and two service user surveys out of ten sent out were returned. These documents and the site visit were the main sources of information for the key inspection. During the site visit the inspector spoke with three service user; interviewed the manager, assistant manager and three members of staff; toured the premises; looked at records; case tracked; and observed the interaction between service users and staff. Twenty-six standards were assessed of which sixteen were met and ten were nearly met. Three requirements and six recommendations were made. Four service users were staying at the home when the site visit took place. What the service does well: What has improved since the last inspection? Service users are having greater choice about how they spend their time at the home; being consulted about what activities they would like to take part in; being encouraged and helped to be more independent; enjoying a more flexible approach to meals and mealtimes; their views are being sought as part of a quality assurance and quality monitoring system; their care plans are starting to be updated and reviewed; and they are benefiting from a more flexible approach to staff duty rotas in order that the number of staff on duty reflects the needs of the service users. In addition, two more staff are studying for a NVQ 2 in care; four new care staff have been recruited and will start as soon as their recruitment checks have been completed; supervision of staff is starting to take place; there is effective communication between management and care staff; staff said morale is gradually improving; the home has started to be renovated; fire drills are taking place at least twice a year; individual files and medication records have a photograph of the service user; and a new manager is in post. Waymead Short Term Care DS0000031646.V310393.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. Waymead Short Term Care DS0000031646.V310393.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 Waymead Short Term Care DS0000031646.V310393.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Number 2. Quality in this outcome area is good. Prospective service users’ individual aspirations and needs are assessed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No new service users are receiving respite care so assessments of recently admitted service users could not be assessed. At the previous inspection full assessments had been undertaken on new service users. Waymead Short Term Care DS0000031646.V310393.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 6, 7 and 9. Quality in this outcome area is adequate. Every service user has an individual care plan and staff have started updating them to ensure they contain the necessary information to meet the service users’ needs and aspirations. Reviews of the care plans, which had not been done until the last couple of months, are now starting to take place. Service users are enjoying greater choice about what they do while at the home. Staff encourage and enable service users to be more independent and take risks. The majority of risk assessments need to be reviewed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some of the care plans have been revised using the new ‘Person Centred Planning’ format and now contain the necessary information to meet the current and changing needs of the service users. However the majority still require updating. The majority of the staff have received ‘PCP’ training and the manager has set a deadline for all care plans to be updated by the end of November 06. It is vitally important that this takes place, as important up to date information needs to be included in the plans. One service user’s file did Waymead Short Term Care DS0000031646.V310393.R01.S.doc Version 5.2 Page 10 not have information about nuts exacerbating his asthma nor were their details of an exercise programme recommended by the GP to assist with his oxygen deficiency. All files now contain a photograph of the service user. Reviews of the care plans are now starting to take place that involve the service user, primary carers, key workers, day centre staff and appropriate outside professionals. These will take place once a year. The inspector recommended that an internal review should take place in between the annual reviews. The two service users who returned their surveys said they usually make decisions about what they do each day and can do what they want to do during their stay. Service users interviewed said they usually choose what they do during their stay, can have the room that they want and staff usually ask them what they would like to do. Staff said service users are involved in the decision making process of running the home, i.e. choose the pictures for the home, what purchases should be made for the home, the food they would like to eat and what activities that should be on offer. In response to comments in the service user feedback forms, a bed has been replaced because it was uncomfortable and staff will be provided for a service user to go out with his girl friend. For service users who do not look after their own personal money a system is in place for recording transactions and securely storing their money. Service users who look after their own money have the use of lockable drawers in their rooms. The inspector was informed a regular audit takes place. Detailed reviews of risk assessments have taken place on the service users with the greatest needs but the majority of service users still need to be reviewed. Staff are now instructed to encourage and enable service users to be more independent and take risks, i.e. make own packed lunches and help in the kitchen. Waymead Short Term Care DS0000031646.V310393.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. The range of activities on offer to service users in the home and in the community is limited. The management team is working hard to rectify this situation and also enable service users to engage in activities of their choice and become part of, and participate in, the local community. Service users are supported to maintain family links and friendships inside and outside the home. The home promotes independence, individual choice and freedom of movement. Service users are offered a healthy diet and enjoy their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The majority of service users go to the day centre during the day. Service users said they go out but would like to go out more often and get bored at times. The manager is aware of the need to improve the range of activities on offer and the opportunities for service users to engage in the activities of their choice. He plans to manage the booking system so service users of a similar age and with similar interests have respite at the same time. This would enable service users to engage in more activities of their choice. The manager Waymead Short Term Care DS0000031646.V310393.R01.S.doc Version 5.2 Page 12 has purchased a music centre and a computer that will have Internet access. The manager would like service users to participate in clubs and facilities used by the general public rather than specifically for adults with learning disabilities. At present, service users go to the Challenge club on a Wednesday evening; shopping in town; to a place of worship if they request; for walks; on outings; and to pubs etc. The management team is trying to increase contact and involvement with the community. They have encouraged local businesses to support fund raising events, recruited a local musician to come in to run drumming sessions and a local artist to come in and organise artistic projects such as painting murals on some of the walls. They would like to recruit volunteers to accompany service users on outings and engage in activities in the home. Relatives and friends can visit the home at any reasonable time. Service users said the home tries to arrange for service users who are friends to stay at the same time. Staff are now encouraging and enabling service users to be more independent i.e. making packed lunches, cleaning rooms, doing laundry, helping in the kitchen. Service users were observed freely moving about the home as they wish and mixing with other service users. A service user said he helps with food preparation. Service users said staff would listen and talk to them. There are clear rules on smoking and alcohol consumption in the home. The manager has introduced a more flexible approach to meals and mealtimes. Service users, within reason, can now choose what they would like to eat and when. Dietary and cultural requirements are catered for. Service users said they like the choice of meals. Service users said they could help with the preparation and cooking of meals. Waymead Short Term Care DS0000031646.V310393.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 18, 19 and 20. Quality in this outcome area is good. Service users receive personal support in the way they prefer and require. Their physical and health needs are met. Staff comply with the medication policy and procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the service users spoken with and who returned the surveys said staff are nice, treat them well and they like coming to Waymead. They also said staff listen to them and act on what they say. They get up and go to bed when they want and watch TV as long as they like. Staff were observed to treat service users in a caring manner. It is planned for all staff to receive diversity training in the coming year. As service users are only resident for short periods of time the main responsibility for their healthcare needs rests with their primary carers. Should they need outside medical support it is arranged or relatives are contacted. Service users said staff support them with their healthcare needs, i.e. dress his ulcers every day. As referred to in standard 6, health care records must include all current health issues to ensure service users’ health needs are dealt with appropriately. Waymead Short Term Care DS0000031646.V310393.R01.S.doc Version 5.2 Page 14 The procedure for recording the administration of medication has been revised to ensure less room for error. A support plan front sheet, which includes key information, is attached to the records together with a photograph of the service user. The administration records seen were in order. Waymead Short Term Care DS0000031646.V310393.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 22 and 23. Quality in this outcome area is good. Service users feel their views are listened to and acted on. Service users are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure in place. Service users said staff listen to them and they would talk to a member of staff or the manager if they had a complaint. ‘Complaints leaflets’ explaining how to make a complaint are in an ‘easy read’ format. They are given to service users and their relatives when first admitted. No complaints have been made since the last inspection. Procedures for responding to suspicion or evidence of abuse are in place. Staff have received ‘protection of vulnerable adult’ training. Staff know how to respond to allegations and suspected incidents of abuse and would inform management if they suspected another member of staff was abusing a service user. No allegations of abuse have been reported to the Commission since the last inspection. There is no physical intervention and restraint policy and procedures in place. Waymead Short Term Care DS0000031646.V310393.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 24, 26 and 30. Quality in this outcome area is adequate. Much needed decoration and renovation of the home is taking place. The management team should ensure the bedrooms are not used to store items surplus to their requirements and all the beds are comfortable. The home is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has started to be renovated. New windows and flooring in the dining area have been fitted and new furniture has been purchased. The manager wants the use of communal rooms to change to better meet the individual and collective needs of the service users. As this takes place the rooms will be decorated as well as the service users’ bedrooms. New external doors are to be fitted and more furniture replaced. The downstairs bathroom is being enlarged and a new bath and specialist hoist installed. Service users can have the use of a bedside light in their rooms and can bring their own portable TVs if they wish. The manager plans to have ‘personal belongings’ boxes for each service user so they can personalise the room they use. One service user said the bed he uses makes ‘noises’ when he tries to Waymead Short Term Care DS0000031646.V310393.R01.S.doc Version 5.2 Page 17 get to sleep and another service user said the bed hurts her back. A service user said there is always bedding, pillows and boxes of clothes he doesn’t use in his room. The home was clean and hygienic on the day of the site visit but a service user said there is always dust on the windowsill of the room he sleeps in. Two service users who returned their surveys said the home is always fresh and clean Waymead Short Term Care DS0000031646.V310393.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 32, 33, 34, 35 and 36. Quality in this outcome area is adequate. The home has a core of experienced and knowledgeable care staff. There is a very high reliance on relief and agency staff which is hoped will be remedied when four new staff start work in the near future. The manager is introducing a more flexible approach to staff duty rotas in order that the number of staff on duty reflects the needs of the service users. The organisation is operating a thorough recruitment procedure. All the permanent care staff have attended the necessary basic training courses, but only two care staff have a NVQ2 in care or above and LDAF has not been incorporated into the training programme. Staff feel more supported and regular supervision of all staff has just started to take place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff interviewed were knowledgeable about the conditions and needs of the service users. Two permanent members of staff have a NVQ 2 or above in care. Two staff are working towards a NVQ 2 in care. The management team is encouraging staff to develop a more modern ‘enabling’ approach to service users but at the same time recognising that many service users benefit and welcome being ‘cared for’. Waymead Short Term Care DS0000031646.V310393.R01.S.doc Version 5.2 Page 19 In addition to the manager, the home’s permanent staff compliment is, two assistant managers (one of whom is currently undertaking professional training, but still has responsibilities within the services whilst not at university or on placement), three full time care staff, one part time care staff, two night staff, a part time administrative person and a driver/handyman. The home continues to rely heavily on relief and agency staff to cover the vacant care hours. In the last year agency staff or relief staff were employed on three hundred days. Four new care staff have been recruited and will start as soon as their recruitment checks have been completed. Three service users with very high needs are now financed to have one to one care during the day. Sick leave is not as high as at the last inspection. Staff said morale is gradually improving. The manager is introducing a more flexible approach to staff duty rotas in order that the number of staff on duty reflects the needs of the service users. Together with the finance for staff to be employed to provide one to one care and the recruitment of four new staff, service users should begin to enjoy more consistent care, greater choice and more recreational opportunities. No new staff have started working in the home since the last inspection. At the last inspection records showed the home operates a thorough recruitment procedure. New staff receive induction and foundation training. The organisation is planning to incorporate Learning Disability Award Framework training with the induction and foundation training. Records showed all the permanent care staff have received basic training including first aid, adult protection, manual handling, and food hygiene. The majority of permanent staff have also received training on dementia care, medication, person centred planning and physical intervention. As staff receive an appraisal with their line manager their training needs, including refresher training, will be assessed. Staff said a wide range of training opportunities are on offer. Records showed staff meetings take place every one/two weeks. Records showed supervision of permanent and relief staff is starting to take place. One member of staff said she has had two supervisions since the manager has been in post. A relief member of staff said she has not received supervision yet. Staff said they feel more supported. The manager said staff are starting to have annual appraisals. The manager is planning to organise team-building events when the new staff are in post. Waymead Short Term Care DS0000031646.V310393.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 37, 38, 39 and 42. Quality in this outcome area is good. The manager is qualified, competent and experienced to run the home. The management approach of the home is open, positive and inclusive. An effective quality assurance and quality monitoring system is being developed. The manager ensures so far as is reasonably practicable the health, safety and welfare of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new manager has been in post for thirteen weeks. He has relevant experience and achieved the Registered Manager’s Award, a NVQ 4 in care and is an assessor for NVQ qualifications. Staff said the management of the home is now clearer and more positive. There are clear plans about what needs to change and why. Staff are encouraged to voice their views and concerns. Staff said they are more optimistic and hopeful for the service. Waymead Short Term Care DS0000031646.V310393.R01.S.doc Version 5.2 Page 21 Service users are now asked to complete a feedback form (in a service user friendly format) after each period of respite care. The service users are asked to comment on activities; standard of their bedrooms; level of care and support; and choice. Service users who cannot complete the forms will be observed during their stay and a member of staff will complete a form on their behalf. The manager is trying to set up a service users’ committee, but has had difficulties finding an independent chair. Regular regulation 26 visits and reports are being completed. The locality manager, learning diabilities, in conjunction with the learning disabilities’ management team will develop a strategy for the future development of services for adults with a learning disability in Bracknell Forest. This will include services to carers, of which Waymead Short Term Care is currently a part. All necessary health and safety checks, audits and inspections are taking place. The home is responding to all the recommendations made by the Fire Safety Officer at his recent inspection of the home. The recommendations include producing an up to date fire risk assessment, fitting self-closing mechanisms to all the bedroom doors, and ensuring all fire doors close and fit properly. Records of all accidents and injuries are kept and copies sent to the Health and Safety officer who monitors them for any issues or trends that need addressing. Waymead Short Term Care DS0000031646.V310393.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 X 2 3 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 2 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 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Waymead Short Term Care DS0000031646.V310393.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 Requirement Care plans and risk assessments must contain more detail in key areas of a service user’s care. (Outstanding from 02/08/05 inspection) The service user’s plan must be kept under review. (Outstanding from 02/08/05 inspection) Regular supervision of all staff to take place Timescale for action 30/11/06 2. YA6 15 31/03/07 3 YA36 18 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard YA6 YA9 YA18 Good Practice Recommendations Internal reviews of care plans should take place in between the annual reviews. Ensure all risk assessments are reviewed at regular intervals. LDAF should be incorporated in the staffs’ training programme. DS0000031646.V310393.R01.S.doc Version 5.2 Page 24 Waymead Short Term Care 4 5 6 YA23 YA24 YA26 A physical intervention and restraint policy should be produced. An annual development plan should be produced The management team should ensure the bedrooms are not used to store items surplice to their requirements and all the beds are comfortable. Waymead Short Term Care DS0000031646.V310393.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 Waymead Short Term Care DS0000031646.V310393.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. 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!