Inspection on 10/07/06 for Wendover Road (87)

This inspection was carried out on 10th July 2006.

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

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

Other inspections for this house

Wendover Road (87) 27/08/08

Wendover Road (87) 28/08/07

Wendover Road (87) 21/11/05

Wendover Road (87) 19/04/05

Wendover Road (87) 24/01/05

Wendover Road (87) 06/08/04

Wendover Road (87) 11/02/04

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Wendover Road (87) Stoke Mandeville Aylesbury Bucks HP22 5TD Lead Inspector Chris Schwarz Unannounced Inspection 10 and 26th July 2006 09:30 th Wendover Road (87) DS0000023084.V295735.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 Wendover Road (87) DS0000023084.V295735.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. Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wendover Road (87) Address Stoke Mandeville Aylesbury Bucks HP22 5TD 01296 615403 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) 87wendrd@nildram.co.uk Hightown Praetorian & Churches Housing Association Mrs Tracey Siever Care Home 4 Category(ies) of Learning disability (4), Physical disability (2) registration, with number of places Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home may care for two service users with a Learning Disability, who also have a Physical Disability. That this condition applies to two specific service users, and should the service users in question leave the home for whatever reason this condition will cease to apply. That no further users with a physical disability are admitted to the home unless the home applies for a further variation to their registration. Date of last inspection 21st November 2005 Brief Description of the Service: 87 Wendover Road cares for 4 female service users with a learning disability. The home is located in a residential area about one mile from the centre of Stoke Mandeville. The home is a bungalow situated in relatively secluded grounds, with a large rear garden. All of the bedrooms are single and there is a kitchen / diner and a separate sitting room. The home has its own transport and is accessible to local amenities. Fees for this service are £1735.44 per week, according to information supplied with the pre-inspection questionnaire. Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over the course of one and a half days and consisted of discussion with the manager and external line manager, meeting with staff and service users, a tour of the premises and examination of some of the home’s required records. Prior to the visit, a pre-inspection questionnaire was sent to the manager for completion, alongside comment cards for distribution to service users, relatives and health care professionals. No replies were received. Staff and service users are thanked for their co-operation and hospitality during the inspection. What the service does well: Needs arising from equality and diversity are well met. Service users are enabled to make every day decisions, with support from staff and advocates, providing choice. Service users take part in a range of activities and pastimes, providing them with stimulation, variety and involvement in the local community. Contact with family and friends is supported, ensuring that important social relationships are maintained. Rights and responsibilities of service users are respected, ensuring that they have choice and fulfilment. Varied and wholesome meals are provided for service users, to meet their nutritional needs. Service users receive personal support according to their needs. Physical and emotional needs are well met, keeping service users healthy. Medication is appropriately managed at the home, ensuring that service users receive the medicines they require to keep healthy and well. There are effective complaints procedures for service users’ representatives to share their views. Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 6 Adult protection and whistle blowing procedures are in place to reduce the risk of harm to service users. An attractive, clean and homely environment has been created for service users, providing them with comfortable surroundings. Service users are cared for by staff who have a understanding of their needs and are competent to provide care. Robust recruitment practices are in place, to ensure that service users are cared for by competent and scrupulous persons. The home has a permanent manager, to ensure continuity of care for service users. There is effective monitoring of the service by the provider, to ensure that standards are sufficient to meet care needs. What has improved since the last inspection? What they could do better: Policies and procedures are in place to provide guidance on the process of admitting new service users but these need to be supplemented with Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 7 admissions criteria, to ensure that referrals are appropriate and within the scope of the service. Care plans and individual risk assessments need to be updated to accurately reflect current needs, to ensure that service users receive the assistance they require. Pictorial procedures for service users to make complaints need to be completed. Some attention is needed to the management of challenging behaviour to ensure that staff respond appropriately to service users. Some further work is needed to supplement measures in place to safeguard health and safety at the home. Training needs to be brought up-to-date and maintained as such, to ensure that staff have the necessary skills and knowledge to meet service users’ needs. 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. Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 8 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 Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. Policies and procedures are in place to provide guidance on the process of admitting new service users but these need to be supplemented with admissions criteria, to ensure that referrals are appropriate and within the scope of the service. EVIDENCE: There have not been any new admissions to the home. Existing service users’ needs were carefully documented prior to moving to 87 Wendover Road and involved multi-disciplinary input. There is a corporate admissions procedure to refer to in the policy handbook to provide guidance on the process that the manager would need to use should a vacancy arise in the future. A requirement from a previous inspection to produce admissions criteria for the home had not been met and needs attention by the manager. Wendover Road (87) DS0000023084.V295735.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. Care plans and individual risk assessments need to be updated to accurately reflect current needs, to ensure that service users receive the assistance they require. Service users are enabled to make every day decisions, with support from staff and advocates, providing choice. Some attention is needed to management of service users’ finances to ensure adequate safeguards are in place. EVIDENCE: A sample of care plan folders was examined. There was a mixture of well organised and mostly up-to-date documents, with evidence of review and some which were less organised, in need of updating and no recent evidence of reviewing. The same applied to individual risk assessments, which could mean that service users’ needs are not fully met. Some information needs to be clearly written, for example one person’s needs arising from their sexuality were written without saying how the needs could be met. Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 11 The needs of a service user from an ethnic minority were well documented and clearly stated the type and amount of support required regarding personal care and lifestyle and staff were following this. The efforts of the staff team to put files into better order are acknowledged. However, requirements were made at the last inspection for these areas to be improved and there are signs of some improvement at the home but not sufficient for the requirements and standards to be met. The requirements are repeated on this occasion. From observation of staff practice, it was possible to see that service users were offered choices, such as meal options, drinks, whether the inspector could look at their rooms/check medication cabinets and they had freedom to move around the home and garden. Service user meetings take place and minutes are available of these. Some had been attended by an advocate and continuing use of advocacy services is being evaluated. The home looks after money on behalf of service users and the records and balances of two people were examined. Individual transaction sheets and locked tins are used and receipts are in place to explain expenditure. One receipt contained a loyalty card number which did not belong to the service user and was later traced to a member of staff. Measures have been put in place to prevent accidental use of the wrong card and staff have been reminded that further incidents would need to be dealt with under disciplinary guidelines. Curtains had been purchased on behalf of another service user; there was no evidence of agreement by the external appointee for these to be bought following redecoration of the service user’s bedroom. It is recommended that written authorisation be obtained and kept with the transaction records, to verify agreement. Recorded balances and actual balances of money tallied and the tins are checked and recorded as part of staff handover and at the end of the day if any activities have taken place where expenditure was incurred. The home’s missing person procedure had been updated, as required. None of the people living at the home have gone missing. Wendover Road (87) DS0000023084.V295735.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. Service users take part in a range of activities and pastimes, providing them with stimulation, variety and involvement in the local community. Contact with family and friends is supported, ensuring that important social relationships are maintained. Rights and responsibilities of service users are respected, ensuring that they have choice and fulfilment. Varied and wholesome meals are provided for service users, to meet their nutritional needs. EVIDENCE: Observation of movements during the day and daily notes provided evidence of service users being involved in a number of activities and pastimes, making Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 13 use of taxis and the home’s own tail lift transport. A group for Asian people was being regularly attended by a service user, maintaining further links with her culture. There are plans to convert the garage at the home to a multi-sensory room in the future. Personal files contained details of each person’s food likes and dislikes. and the support they need with mealtimes. Different menus are in place for each person with records kept of which meals have been provided and how the service user made the choice. The kitchen was well stocked and dates of opening had been added to items in the fridge. Plans are underway to make the kitchen a safer place for service users, to prevent injury when meals are being prepared. Care plan folders contained lists of family and friends for each service user and important dates to remember. Daily notes provided evidence of keeping in contact with friends living in other parts of the county and seeing relatives. Routines around the home were flexible and service users were permitted to be alone or in company, as they wished. Bedroom space was regarded as a private area and service users had the freedom to use the garden or be inside. There was no need for rules on alcohol, smoking or drugs. Wendover Road (87) DS0000023084.V295735.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. Service users receive personal support according to their needs. Physical and emotional needs are well met, keeping service users healthy. Medication is appropriately managed at the home, ensuring that service users receive the medicines they require to keep healthy and well. EVIDENCE: Personal support guidelines were in place in care plan folders, some of which may need reviewing and revision of risk assessments, as mentioned earlier in the report. Needs arising from equality and diversity were well met by staff through provision of same gender care, adherence to cultural practices and styles of clothing. A requirement regarding exercise/massage programmes was no longer applicable. Service user weights are now largely the responsibility of the dietician who maintains records at the hospital. Some positive weight loss has resulted in increased mobility for one person. Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 15 Records of medical appointments provided evidence of service users receiving support from a range of health care professionals and preventative action such as influenza vaccination. Medication cabinets have been fitted in each bedroom, providing secure storage. Records of medication administration were in good order, with no gaps alongside prescribed doses, and a second sheet has been devised for the person witnessing administration to add their initials. Medication is checked each day as part of staff handover and the monitored dose system seems to work well for service users’ needs, with periodic inspection by the supplying pharmacist. Protocols were in place for prescribed “as required” medicines. Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. There are effective complaints procedures for service users’ representatives to share their views. Procedures for service users were incomplete. Adult protection and whistle blowing procedures are in place to reduce the risk of harm to service users. Some attention is needed to the management of challenging behaviour to ensure that staff respond appropriately to service users. EVIDENCE: A corporate complaints procedure is in place and the complaints file showed that no fresh complaints have been made since the last inspection. The Commission had not received any complaints about the service. Pictorial complaints formats are in each person’s files although none of those seen had been completed in full. A requirement is made for this to be attended to. The continued use of advocacy services at the home is positive and to be encouraged. Adult protection procedures are in place and whistle blowing/public disclosure guidelines are contained within the organisational policy folder. The Commission is not aware of any adult protection concerns relating to this service. Staff undertake initial training on adult protection and management of challenging behaviour as part of induction. During the course of the inspection, staff could be heard from one end of the building to the other speaking Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 17 brusquely and saying “No” to a service user and “Wait”, plus observation of staff and service users in the dining area gave rise to some concerns about how service users are responded to at times. The manager is advised to look at who was on duty at that time and ensure that any poor conduct by staff is addressed. Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. An attractive, clean and homely environment has been created for service users, providing them with comfortable surroundings. EVIDENCE: The home has been adapted to a good quality residence for people with disabilities and is not distinguishable as a care home from the road. Each service user has a large single bedroom, decorated and arranged to individual tastes. Communal rooms comprise a kitchen with dining area overlooking the garden and with a door leading outside, a small lounge, laundry and a bathroom and separate toilet. The office and sleeping in rooms are small but usable. Some of the paintwork around the building has been chipped, such as architraves and where chairs have scraped along walls. Investigation into damp on one of the bathroom walls has not revealed the cause and the organisation’s estates department is aware of the problem. Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 19 Work is planned to convert the garage to a multi-sensory room and there are plans to repave the path leading from the kitchen to remove the gradient, making is safer for wheelchair users. All parts of the home were clean, odour free and well ventilated on both days of the inspection and the laundry in good order. There is parking at the front of the property for several vehicles. Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. Service users are cared for by staff who have a understanding of their needs and are competent to provide care. Robust recruitment practices are in place, to ensure that service users are cared for by competent and scrupulous persons. Training needs to be brought up-to-date and maintained as such, to ensure that staff have the necessary skills and knowledge to meet service users’ needs. EVIDENCE: Sufficient numbers of staff were on duty on both days of the inspection. The team is currently all female and there were two vacancies, one on day shifts and one on nights and recruitment was underway to fill these. Use of agency staff had reduced since the last inspection and there was written information supplied by the agency/ies to confirm that required vetting checks had been undertaken and to outline the individuals’ training histories. It was good to see that the home had this information in place and had made a list of which agency staff had been vetted, for shift leaders’ information when needing to cover rotas. Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 21 There had only been one new permanent recruit to the home since the last inspection. All required checks were in place for this person. The induction package for new staff is detailed and covers all necessary areas of care practice including competency to administer medication. Two induction programmes were viewed and these were signed to verify which parts had been covered. Staff meetings take place on a regular basis and minutes are kept of these. Handover between shifts is well structured, professional and provides good safeguards for ensuring that information is passed on and that procedures are followed. Staff spoken with during the course of the inspection had worked at the home or with the group of service users for varying periods of time, some for a few months and one for thirty years. The manager, assistant manager and external line manager have had involvement for about a year and it is acknowledged that the home needed a lot of time and attention to improve standards at the time they started. Training records showed that various courses have been booked to ensure that mandatory training is brought up to date. For a sample of staff records examined, none had the full range of up-to-date training already in place. In addition to this, all staff need to be updated yearly on both adult protection and fire safety, which can be done in-house to supplement the organisation’s or external courses that are on offer. A requirement is made to address this. Four staff have achieved National Vocational Qualification (NVQ) at level 2 or above and a further two are undertaking NVQ. The manager is yet to commence the Registered Managers’ Award/NVQ level 4. Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the inspection, which included a visit to the service. The home has a permanent manager, to ensure continuity of care for service users. There is effective monitoring of the service by the provider, to ensure that standards are sufficient to meet care needs. Health and safety is shown due regard at the home, to ensure that the risk of accident injury is reduced. Some further work is needed to supplement measures in place. EVIDENCE: The manager has been registered with the Commission since the last inspection. She is expecting to join the next intake for the Registered Manager’s Award/NVQ level 4 and until this award is achieved the standard Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 23 cannot be scored as met. This should not be viewed as a reflection of a manager’s abilities. There is regular monitoring by the provider and unannounced visits are forwarded to the Commission. copies of monthly A range of health and safety checks is carried out, such as fridge and freezer temperatures, core food temperatures of cooked foods, weekly fire testing, fire drills and quarterly visual hazards checks. Accident and incident records are also maintained and there are now checklists for the first aid boxes. The certificate of insurance for the home’s vehicle was seen and information was available for COSHH products (control of substances hazardous to health) plus a test report for Legionella species. A current certificate to verify gas safety was not in place and there was no portable electrical appliance test report to refer to. Copies of these need to be available at the home to confirm that they have been carried out and that outcomes were satisfactory. During the course of the inspection, there were a few incidents that came to light which the Commission should have been made aware and reported as notifiable occurrences. Examples are the bathroom being out of action and subsequent use of another care home’s facilities and injury caused to a staff member by a service user resulting in a health and safety investigation by the provider. A requirement regarding notification made at the last inspection is not being complied with and is repeated on this occasion for urgent attention. Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 2 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 3 x x 2 x Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 25 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 2 Standard YA2 YA6 Regulation 10(1) 15 Requirement Admissions criteria are to be written for the home. Service user files including the pen picture and lifestyle plan must be kept updated to reflect changes in service users needs and to ensure continuity of care. Previous timescale of 31/03/06 not met. Service users’ risk assessments including moving and handling risk assessments must be kept up to date and reviewed. Previous timescale of 31/01/06 not met. Service user complaints procedures are to be completed in full. The manager is to ensure that deficiencies in staff responding to service users being challenging are addressed. Mandatory training is to be brought up-to-date. Input on fire safety awareness and adult protection is to be refreshed annually. The organisation must ensure that any event which affects the well-being of service users is DS0000023084.V295735.R01.S.doc Timescale for action 01/01/07 01/10/06 3 YA9 13 01/10/06 4 5 YA22 YA23 22(2) 13(6) 01/11/06 01/09/06 6 YA35 18(1)c(1) 01/01/07 7 YA42 37 15/08/06 Wendover Road (87) Version 5.2 Page 26 8 9 YA42 YA42 13(4) 13(4) reported to the Commission within 24 hours of occurrence. Previous timescale of 31/12/05 not met. A current certificate of gas safety 01/10/06 is to be available at the home at all times. A current test report of portable 01/10/06 electrical appliance testing is to be available at the home at all times. 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 YA7 Good Practice Recommendations Evidence of authorisation for expenditure by appointees should be kept with service users’ financial records. Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wendover Road (87) DS0000023084.V295735.R01.S.doc Version 5.2 Page 28 - 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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