Inspection on 19/04/05 for Wendover Road (87)

This inspection was carried out on 19th April 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Wendover Road (87) 27/08/08

Wendover Road (87) 28/08/07

Wendover Road (87) 10/07/06

Wendover Road (87) 21/11/05

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 Maureen Richards Announced 19th April 2005 9:30am 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 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 Stationary 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) Version 1.10 Page 3 SERVICE INFORMATION Name of service Wendover Road (87) Address Stoke Mandeville, Aylesbury, Bucks, HP22 5TD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01296 615403 Hightown Praetorian & Churches Housing Association Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Wendover Road (87) Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 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. Wendover Road (87) Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced. It started at 9.30 am and finished at 19.00 hours. This inspection focused on the majority of the key standards and consisted of being introduced to service users, observation of staff engaging with service users, speaking with staff and examining records. A service manager who has been managing the home on a part time basis was present during the inspection, as was a new service manager who will be taking over responsibility for this service. Feedback was given on the standards assessed throughout the inspection. No comment cards or feedback were received on the quality of care provided in the home. Service users are unable to communicate verbally their views on the home and care provided. What the service does well: What has improved since the last inspection? What they could do better: The organisation must ensure that all relevant documentation relating to assessment and care of service users is fully completed, dated and shows evidence of being updated. Service users contracts must be further developed. The log of complaints and outcome must be made available in the home. Wendover Road (87) Version 1.10 Page 6 The grass must be mowed and the garden kept maintained. The organisation must ensure that safe staffing levels are maintained and that records are provided to ensure that proper employment checks are carried out on staff. The most serious concern from this inspection was that untrained and inexperienced staff are on duty. An immediate requirement letter was left at the home to inform the organisation that this must be put right. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wendover Road (87) Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Wendover Road (87) Version 1.10 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 standard(s) 2 and 5 Assessment documentation for new service users is not fully completed and neither the admissions procedure or statement of purpose outline a clear admission criteria. This could result in prospective service users not being fully assessed prior to admission and in service users being admitted whose needs cannot be met. Service users contracts have not been developed in line with standard 5.2 and therefore the terms and conditions of admission are not fully outlined to service users. EVIDENCE: The home has had no new admissions since the previous announced inspection. The service user who was admitted at that time appears to have settled in well and community resources and support have been accessed to support this individual. The service manager confirmed that the assessment of potential service users takes place over a long period of time, prior to admission and this assessment continues on admission. The organisation has detailed assessment documentation which identifies the prospective service users’ personal details, occupation, significant people in that person’s life, height, weight, medical and health needs, medication, personal care needs, self care skills, sleep pattern, domestic skills, finances, social interaction, communication, emotional, behavioural needs and cultural and religious needs. Wendover Road (87) Version 1.10 Page 9 The service manager confirmed that the manager of the home is actively involved in the assessment process and that as much information is gathered from other professionals and significant people involved with the service users to assist the assessment process. However the assessment documentation for the newest service user to the home was not fully completed. The home has an admission of new people procedure. This procedure outlines the steps to take prior to admission and on admission but does not include the criteria for admission. The home does not accept emergency admissions and this is outlined within the statement of purpose. However the statement of purpose also does not outline the criteria for admission. This must be included to ensure that all future admissions to the home match the criteria for admission and to ensure that the home is able to met the needs of individuals admitted to the home. Service users files include an individual service user guide, which should outline fees and what they cover. The service users guide seen did not have this information completed. The service user guide does not include a signature and therefore this information should actually be outlined in a contract, which is signed by the service user, representative or advocate. Service user files include a written and pictorial licence agreement. This licence agreement refers to unacceptable behaviour but does not outline the notice period that would be given if this behaviour was presented. The licence agreement outlines that rent increases annually but does not actually outline the rent charges at the point of admission. It does not identify how much the service user is expected to contribute to those charges or what the charge actually covers. The organisation must develop the contract in line with standard 5.2. Two pictorial licence agreements were seen, one was unsigned and the second was signed but it was not clear who had actually signed it. The signature was unknown to the service manager. None of the current service user group are able to write their signature. The organisation must ensure that contracts are explained to service users and signed by their representative or advocate. Wendover Road (87) Version 1.10 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 standard(s) 6,7 and 9. Service users care files are detailed and specific to meet their needs in a consistent way, however some guidelines do not include a date of implementation, evidence of review or discussion with service users, which could potentially put service users and staff at risk. Service users are supported to make decisions about their lives, which enables them to be involved in all aspects of their care and life at the home. There was insufficient detail in some risk assessments which could compromise the safety of service user’s. EVIDENCE: Each service user has three files which are colour coded to indicate whether they are care files, daily files and finance files. The care files seen include an index, they are well organised and the information is accessible. Care files seen include a photograph, key information and a record of hospital admissions. These care files provide detailed specific guidelines on supporting individuals in all aspects of their lives. However the guidelines did not include a date of implementation or evidence of being reviewed and were not signed to indicate Wendover Road (87) Version 1.10 Page 11 who had developed the guidelines. There was no evidence of those guidelines being discussed with the service user. The care files included detailed information on things that are important to individuals. They also included personal achievement guidelines such as how the individuals religious needs are met, how the service user communicate, how the service user learns. Service user care files outlined their getting up and going to bed routines, their involvement in domestic tasks, their food and drinks choices and reference to leisure activities. These guidelines were dated, signed by staff and included a date of review. However none of the guidelines showed any evidence of a written review. The service manager confirmed that those guidelines are reviewed as indicated by review date and are reprinted on review to include any changes. Evidence of a written review of personal guidelines must be included as part of the care file. One service user’s care file included a communication profile, which did not include the date of implementation or again show evidence of being reviewed or updated by professionals involved in that persons care. Service users files indicate that they are involved and consulted in decisions within the home. Service users files include evidence of them recently being consulted on the choice of paint for the hallway. Service users care files indicate that other professionals, for example the speech and language therapist and advocate, are involved in supporting staff to enable service users to communicate and make decisions. The home has an advocate who holds a monthly meeting with service users. The service manager confirmed that those meetings had recently been less frequent. Service user care files make reference to the support required by individuals in making choices. The service manager confirmed that the linkworker meets with the service users and supports them to meet their personal goals and aspirations as outlined in the care file. The service manager confirmed that the organisation acts as an appointee for one service user. The home keeps a record of the service users monthly expenditure and receipts and this is audited monthly against the bank statement. The organisation carries out an annual audit of the home’s financial records. Each service user plan includes a series of risk assessments. The risk assessments identify the risks and includes a management plan to reduce the risks identified. Each risk assessment is numbered and includes a written review of the risk and indicates if any changes have occurred. The risk assessment is signed off by the staff member and manager. Some of the risk assessments seen did not outline the level of risk and none of the risk assessments indicate that they have been discussed with the service users or utilised the advocate to ensure that the key information from the risk assessments could be made known to the service users. Service users plans include separate risk assessments for managing behaviours and separate moving people risk assessments. Staff carry out the moving people assessments and refer to the moving and handling trainer for Wendover Road (87) Version 1.10 Page 12 advice in specific situations. Written communication in individual service user care files support this. The home has a copy of the organisation’s missing person interim procedure. which was reviewed in December 2003 and is due for review in December 2006. This procedure does not outline that the Commission must be informed if a service user goes missing. The procedure must be updated to include this. Wendover Road (87) Version 1.10 Page 13 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 standard(s) 12,13,15,16 and 17. Service users have an individual programme of activities and therefore their individual interests and cultural needs are taken into consideration. Service users are supported to take part in activities to enable them to have a community presence. Family involvement is supported and encouraged to enable service users to develop and maintain appropriate relationships. Service users’ care files do not fully indicate how service users post should be managed and therefore may compromise their privacy. The home promotes service users choice and involvement in meals, providing them with a varied and balanced diet. EVIDENCE: Service users have an individual programme of activities specific to their needs and cultural background. Staff support service users with their programmes. Wendover Road (87) Version 1.10 Page 14 Service user files indicate evidence of service users being involved in making choices in activities and in staff identifying service users hobbies and interests. Each file contains a daily activity record form of what activity has taken place. The home has a leisure resource folder and staff find out what events are happening locally. The service manager confirmed that the home has maintained links with other homes whereby service users maintain relationships with people they know. The manager confirmed there are no current issues with neighbours. The home has it own transport. The service manager confirmed that service users are only expected to contribute to the transport costs for activities, which are not part of the programmed activities. The service manager confirmed that service users are on the electoral roll and are looking at ways in which service users can be supported to vote in a meaningful way. The rota indicates that three staff are on each shift during the day, which allows them to support service users with their programmes and activities. The service manager confirmed that extra staff can be provided for specific, planned activities. Service users files make reference to individuals specific cultural needs and the home has a calendar of all religious celebrations. Service user plans make reference to family involvement and wishes. There are guidelines for visitors included within the service user guide. Service user plans make reference to promoting independence, which is meaningful to that individual. Service users are supported and encouraged to lock their bedrooms when going out. The service manager confirmed that staff are aware that service users post must be opened and read with them in private. There was no reference to this in service users files. During the inspection it was noted that one service user’s name was abbreviated to another name. There was no reference to this on the individuals file or personal details information. The staff prepare and cook three meals a day. The menu is planned weekly and service users are encouraged to make a choice of meal by the use of items and pictures. The home keeps a record of service users responses to items shown and indicates how the decision was made. Staff support service users to eat their meals and individuals care files outlines the level of support required. Wendover Road (87) Version 1.10 Page 15 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 standard(s) 18,19 and 20 Personal support is provided which promotes and protects service users privacy and dignity. The home has excellent records to indicate that service users health needs are met and followed up by a wide range of professionals. The medication is well managed in accordance with organisational policies and procedures ensuring proper administration. EVIDENCE: Service user care files make reference to the level of support required in meeting their personal care needs. Preference on how service users are moved and guided are outlined within care files or specific moving people assessments. The home has four female service users and the staff team are all female, therefore personal care is provided by staff of the same gender only. The service manager confirmed that some service users are able to get themselves up and put themselves to bed and therefore choose the time they want to do this. The other service users make it known to staff when they want to go to bed and get up. Staff support service users to choose what they want to wear from a choice of two outfits. The home has established good links with the Learning Disability Wendover Road (87) Version 1.10 Page 16 Community Support Team to support them to meet service users needs. Service users have a named linkworker at the home and service user care files outline their preferred routines, likes and dislikes. Service users care files include detailed information on the support required in meeting individuals’ physical and medical needs. Records are kept of all appointments with healthcare professionals. which includes the outcome of the appointment and follow up plan if any. None of the service user group are self-medicating. The home has an interim medication policy and procedure on ordering, receiving medication in and dealing with spoilt medication and returns. The medication is administered by staff who have been assessed as competent to administer medication. This assessment is included within the induction pack. An induction pack for a new member of staff was seen which was not fully completed and the medication assessment had been completed but not signed off. The service manager confirmed that all staff involved in medication administration attend the care of medicines training. The organisation does not have any training on the specific medication used at the home, its benefits and effects. The medication administration records were seen which showed no gaps in the administration of medication. One service users medication administration record indicated that some of that individuals medication had been stopped. There was a letter included with the medication administration record from the Doctor to confirm the changes. The home has individual guidelines and protocols for the administration of as required medication. The home has a record of disposal of medication. A requirement was made at the previous announced inspection for guidelines to be put in place on the use of etopaste bandages. The service manager confirmed this had been done, but was unable to find this during the inspection. She agreed for a copy of that procedure to be sent to the Commission. Wendover Road (87) Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The organisation does not make records of complaints concerning the home available in the home and, therefore it is not established if complaints are acted on and dealt with appropriately as outlined within the complaints procedure. The home has policies and procedures in place to safeguard service users. EVIDENCE: The home has a complaints procedure, which outlines how to make a complaint and indicates that complaints will be responded to within 28 days. The statement of purpose and service user guide includes a copy of the complaints procedure. Service users files include a copy of the complaints procedure and a record to indicate that the complaints procedure has been explained to them. However this was last done in August 2003. The organisation should ensure that the complaints procedure is explained and reinforced to this service user group on a more regular basis. The service manager confirmed that there has been one complaint since the pre inspection form was completed, however the organisation has made the decision that all complaints will be kept locked and therefore would be inaccessible as required during inspections. The service manager on duty printed off the log of the recent complaint from the computer. However this did not provide sufficient detail as how the complaint was managed or if it was resolved. The home has an adult protection policy, which was reviewed in December 2004. The policy has been updated in line with interagency procedures. Staff spoken with confirmed that they are clear of their responsibilities in reporting abuse and bad practice. The service manager confirmed that she facilitates the adult Wendover Road (87) Version 1.10 Page 18 protection training and is keen to include this as part of the in house training programme at the home. Training records indicate that some staff have had this training, new staff have been identified to go on this training and dates have been arranged. There is no confirmation if agency staff have had this training. Wendover Road (87) Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 Areas of the home have been redecorated and provide a homely and welcoming environment for service users. However the garden is overgrown and therefore is inaccessible and unsafe for service users. EVIDENCE: Areas of the home have been decorated as required at previous inspections. The home is homely, bright and welcoming. The large garden to the side and rear of the home is overgrown. Staff confirmed that they are expected to keep this grass mowed and the garden maintained. The home is short staffed and the majority of the staff team are agency staff, which has resulted in the garden becoming overgrown, unsafe and inaccessible for service users. Service users could not become involved in mowing and maintaining the garden. Therefore the organisation must consider how it can ensure that this garden is kept maintained, safe and accessible without impinging on care hours. Wendover Road (87) Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 and 35 At times the home does not have adequate staffing levels therefore the needs of service users in and out of the home, their choices and staff and service users safety maybe compromised. Staff personal files do not contain all required information and information supplied on agency staff does not confirm that all recruitment checks have been carried out, which could potentially put service users at risk. Staff do not have the relevant training therefore may fail to meet service users needs. EVIDENCE: The home has a high percentage of staff vacancies. The home uses two agencies to cover the vacancies and the rota indicates that regular agency staff are being used. The rota indicate that there are three staff on each daytime shift. Some service users require one to one input for activities out of the home. An agency staff member confirmed that on occasions she is left alone in the home with at least one, and on occasions two service users. She has felt unsafe in this situation and feels the staffing levels are not adequate at times to allow for service users to be supported by two staff as required with their programmes, whilst allowing other service users to stay at home. Wendover Road (87) Version 1.10 Page 21 Three staff files were looked at during this inspection. The staff files seen were for new staff. The main staff files and original documentation is kept at the head office and copies of all schedule 2 and 4 (6) information are meant to be kept at the home. The staff files seen included an application form, interview assessment, interview questions and answers, medical questionnaire, copy of offer letter or statement of terms and conditions, two references signed off by service manager and CRB clearance. Some files contained a photograph and copies of birth certificates, copy of passport or confirmation of leave to remain in the UK, but not all files contained the information as outlined in schedule 2 and 4 (6). The staff records kept at the home were also found not to contain all of the information required. The home has confirmation from the agencies that staff have got satisfactory references and CRB clearance. However one of the agencies do not include the date of the CRB or the disclosure number. The organisation must request this information from the relevant agencies. The information on file from one agency does not indicate what training staff have had and whether they have up to date safe working practice training. The other agency indicates that staff have all relevant training but it does not outline what this “relevant” training is. The home currently have no staff with an NVQ in care. The training records seen indicate that new staff are working unsupervised with agency staff without mandatory training and on occasions agency staff are working without an experienced permanent member of staff with no indication of what training agency staff have. The service manager confirmed that staff working within this service are expected to have challenging behaviour training. The training records indicate that new staff have not got this training and other members of the staff team last had this training in 2003. There is no indication that agency staff have got this training and the rota indicates that on occasions there is no member of staff on duty with this specific essential training. An immediate requirement was made to address this. Wendover Road (87) Version 1.10 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 39 The organisation has provided management support to the home in the absence of a registered manager to ensure that a high standard of care and support is maintained. The organisation carry out thorough monthly monitoring visits to ensure that standards of care are maintained. EVIDENCE: The home has a registered manager vacancy. A manager has been appointed and is due to start in May 2005. In the interim the home continues to be managed by the service managers. The service managers have provided stability and a lot of support to the home, however the home, service users and staff team will benefit from the continuity of a registered manager. The organisation carries out monthly monitoring of the home. A report is written of the visit, which is detailed and addresses shortfalls as well as positive aspects of the service. However copies of the regulation 26 visits are not forwarded to the Commission following the visit. Copies of visits relating to Wendover Road (87) Version 1.10 Page 23 December, January, February and March were all received together prior to this inspection. The organisation must ensure that this is addressed. It was noted from the four reports seen that action points from the previous months visit are not being followed up or addressed at the next monthly visit. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x 2 Standard No 22 23 ENVIRONMENT Score 1 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No Wendover Road (87) Version 1.10 Score Page 24 LIFESTYLES Standard No 11 12 13 14 15 16 17 Score x 3 3 x 3 2 3 31 32 33 34 35 36 x x 2 2 1 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x x x Wendover Road (87) Version 1.10 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. Standard 2 Regulation 4 Requirement The statement of purpose or admissions procedure must outline the criteria for admission specific to the home.(PREVIOUS TIMESCALE OF THE 31.11.04 NOT MET) The organisation must ensure that the assessment documentation is fully completed for all future admissions to the home. The contract must be developed in line with standard 5.2 and contracts must be signed by service users represenataive or advocate. (PREVIOUS TIMESCALE OF THE 30.09.04 NOT MET) Guidelines on supporting service users to manage behaviours and meet identiifed needs must include a date of implentation, written evidence of being reviewed and confirmation of being discussed with service users or not discussed with service users. All risk assessments must identify the level of risk and indicate if discussed with service users. Version 1.10 Timescale for action 15th June 2005 2. 2 14 15th June 2005 3. 5 5 30th June 2005 4. 6 15 31st May 2005 5. 9 13 31st May 2005 Wendover Road (87) Page 26 6. 9 13 7. 16 12 8. 20 13 9. 22 17 schedule 4 23 10. 24 11. 33 18 12. 34 19 13. 34 19 14. 35 18 15. 35 18 The missing person procedure must be updated to indicate that if a service user goes missing , the Commisson must be informed. The level of support required by service users to manage their post must be outlined within the service user plan. The organisation must ensure that medication assessments are completed and signed off prior to staff taking responsibility for adminstering medication. The organisation must make available in the home a record of all complaints made and a record of the action taken in response to the complaint. The organisation must ensure that the grass is mowed and made accessible and safe for service users. Strategies to be put in place for this to be kept maintained. The organisation must ensure that safe staffing levels are maintained to meet service user needs. The organisation must ensure that all staff files contain all of the information as outlined in schedule 2 and 4(6).(PREVIOUS TIMESCALE OF THE 31.10.04 NOT MET) The organisation must obtain written confirmation from the agencies of individual agency staff CRB disclosure numbers and the date of the disclosure. The organisation must obtain written confirmation from the agencies of what training agency staff have had and date of training. The organisation must ensure that new staff are not working unsupervised and as shift leader Version 1.10 30th June 2005 30th June 2005 31st May 2005 31st may 2005 31st May 2005 31st May 2005 30th June 2005 31st May 2005 19th April 2005 19th April 2005 Page 27 Wendover Road (87) without mandatory training. 16. 35 18 The organisation must ensure that staff do not work unsupervised without challenging behaviour training. The frequency of this training to be agreed with the trainers. The organisation must ensure that copies of regulation 26 visits are forwarded to the Commission following the visit. Reg 26 visits must follow up on action points from previous visits. 19th April 2005 17. 39 26 31st May 2005 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 16 Good Practice Recommendations Service user plans should identify any other names the service user is happy to be called by and staff should only use abbreviations for service users names if this has been agreed and recorded. The organisation should ensure that staff are made aware of the benefits and effects of the medication being adminstered. 2. 3. 20 Wendover Road (87) Version 1.10 Page 28 Commission for Social Care Inspection Cambridge House, 8 Bell Business Park Smeaton Close Aylesbury Bucks, 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) Version 1.10 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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