Inspection on 30/08/07 for West Drive

This inspection was carried out on 30th August 2007.

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 no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

West Drive 10/03/09

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 West Drive 1 West Drive Arlesey Bedford SG15 6RW Lead Inspector Sally Snelson Unannounced Inspection 30th August 2007 10:00 West Drive DS0000069536.V346374.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 West Drive DS0000069536.V346374.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. West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service West Drive Address 1 West Drive Arlesey Bedford SG15 6RW 01462 835490 01462 734975 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) Milbury Darren Rawlings Care Home 8 Category(ies) of Learning disability (8) registration, with number of places West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection This is the first inspection since registration. Brief Description of the Service: The Commission for Social Care Inspection (CSCI) registered West Drive as a care home for up to eight people with a learning disability in March 2007. Since then it has had a phased opening, and at the time of the inspection had six people in place. The home is a detached property in a large secure garden in the Mid Bedfordshire village of Arlesey. The home is currently on the edge of a new housing development being built on the site of an old hospital. It is close to local shops and other amenities. The home benefits from space, as in addition to each of the people using the service having their own large en-suite bedrooms there is a communal lounge, dining room, activity room, and quiet room (with snoozelan equipment) The lounge opens onto decking before the garden, which has yet to be landscaped. There is an outbuilding for which there are plans to renovate it and make it a second activity room for the service users. There is parking inside the grounds and on the road outside. The home is close to a bus route. At the time of the inspection the fees were between £1700 and £2000 per week. West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a care home for adults 18-65 years old that takes account of service users’ views and information received about the service since the last inspection, or in this case registration. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. The inspection of West Drive was their first inspection, was unannounced and took place from 10am on 30th August 2007. The registered manager Mr Darren Rawlings was present throughout and the operational manager joined the inspection. Feedback was given to both at the end of the inspection. During the inspection the care of two people who use the service was case tracked. This involved reading their records and comparing what was documented to what was provided. Because of communication difficulties it was not possible to speak to the service users about their care, but during the inspection service users were observed making their views known. In addition three sets of parents were spoken to. Service user satisfaction surveys had been sent to the home approximately eight weeks prior to the inspection. The manager confirmed with us how they should be completed and was advised as independently as possible. As a consequence they were given to families or advocates to complete with the service users, but none were returned. Staff files were not held in the home. The inspector would like to thank the staff and the customers involved in the inspection for their input and support. What the service does well: Some of the things that are done well include: Before someone moves into the home staff carry out an assessment of their needs. The information that they gather is of a good standard and they make West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 6 sure they find out the individual likes and dislikes of the person. This means staff will know how they should be supporting the person if they decide to move into the home. The staff support and talk well with the service users and the home has a ‘large family feel’ to it. The home makes sure that there are enough staff on duty to look after the service users well. As the home is new, all the furniture and fittings are clean and tidy and not damaged. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. West Drive DS0000069536.V346374.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 West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information provided to the people moving into the home was not always in a format that they could understand which could result in them having limited information at the point a decision is required that West Drive suits them. EVIDENCE: A Statement of Purpose and service users guide had been submitted to us at the time of registration. Since then it had been changed to reflect the changing staff team and the new manager and a new copy was requested. Regulation 6 states that a new copy should have been sent to us within 28days of any changes. These documents had not been prepared in a format that was suitable for many of the service users, for example pictorially. The manager confirmed that there were plans for this but as yet it had not happened. A requirement was made that this should be done. When we registered West Drive in March 2007 there were no service users in the home but some had shown an interest in considering it for the future. Since then the service had had a phased introduction of new service users, West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 9 with the exception of some that were moved temporarily, as an emergency, due to the sudden closure of another home. On the day of the inspection a seventh service user was moved in as an emergency and the parent of a prospective eighth service user was being shown around. For the planned admission it was apparent that short visits would be made to the home for as long as required in order for the new service user to feel it was the correct place for her/him to live. The staff also planned a number of visits to prospective service users in their current care home or school to witness him/her in their own environment as part of the pre-admission assessment. Examination of care files provided evidence that a full assessment by the manager was taken before it was decided that West Drive could meet the needs of service user. This assessment also included information from placing social workers and other professionals involved in the service users care. All of the new service users were admitted to the home with a temporary contract in the first instance and then reviewed. Staff had had the mandatory and specialist knowledge and skills to meet the needs of the service users. This will be discussed in more detail in the staffing section of the report. West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans had been carefully and sensitively written but there was no evidence of service user involvement and some documentation had not been dated or signed which could result in reviews being missed. EVIDENCE: During the inspection an examination of two sets of care records was undertaken. The care plans had been clearly written for all of the activities of daily living and included headings such as personal care, eating and drinking, home life and night care. The plans were divided clearly and gave clear guidelines to staff to ensure a consistent approach to care. They included long and short-term goals and expected outcomes. Because none of the service West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 11 users had been at the home very long there was little evidence that the plans had been reviewed and changed as needs changed. The manager was aware of the need to ensure these plans were used as a working document. However some of the documentation had not been signed and dated by the person completing them and although the plans had been written in a person centred way, for example statements such as “I enjoy going to the library”, there was little, or no, evidence that the plans had been written in conjunction with the service users and/or their families, or the use of the person centred circle. There was little evidence that service users were offered the opportunity to participate in the day-to-day running of the home. For example although staff said menus were chosen by the service users there was no evidence of how this happened and apart from being asked at lunchtime if they wanted jacket potato or quiche there was nothing to indicate how these options had been decided. Since the home had opened there was a record of one service user meeting but nothing to suggest that this was regularly programmed. All of the files included risk assessments; some which were pertinent to the day-to-day behaviours of the service users but others were very generic. For example, one of the service users who care was case tracked had a risk assessment for self medicating when it was apparent that self medicating would not be something he would be able to undertake in the near future. The files sampled included useful information for staff when dealing with a specific service users agitation, which could result in an outburst, and also what to do in the event of a power cut for a service user who could not cope with change. West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This was little evidence that service users were spending their time participating in any meaningful activities, however staff included service users in the general process of running the home such as shopping and cleaning. EVIDENCE: Because the home had not been opened long and because the service users were getting used to living together and ‘settling in’ there was limited evidence that service users were participating in activities. One of the service users attended a day centre and three of the service users had been assessed to attend the local college but none had been on holiday although staff had sourced travel guides to use with the service users when planning breaks. West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 13 During the inspection staff were seen to involve service users in jobs around the home such as making drinks and meals but there was nothing to support how this activity was beneficial for the service user. One of the service users liked going to the library to take out DVD’s but when he came back with staff none suggested they watch it with him or discussed what he had taken out. Another service user had daily-dedicated time on the computer as he like looking at information about trains. This was difficult for the staff as the only computer was in the office and needed by the staff. There was nothing to suggest that staff had pursued this interest and taken him on a train journey or suggested anything else connected with trains. From speaking to staff it was clear that they had some ideas for developing service users and did in fact support them to develop and do activities with them, but there was no documentation to reflect this or individual activity plans. The home had a dedicated activity room that was equipped with a range of games and craft equipment. There was a list of possible activities that service users could participate in but the majority of the service users would not be able to read the list and needed pictorial prompts. During the inspection we witnessed families visiting the home. They were warmly welcomed and offered refreshments. Because the home had a majority of service users who were going through transition, either from the family home to their first placement, or from school they were used to having regular home visits. Each of the service users had unrestricted access to the bedrooms and could meet visitors in them. Some service users held bedroom door keys, other rooms were open and another had a swipe card entry. Throughout the inspection it was noted that staff communicated well with service users. As already stated there was no evidence to suggest that menu planning was a group activity or that service users were involved in choosing what they ate. Records were kept of what service users ate and how much they ate. It was noted that in addition to regular meals the service users were offered regular drinks and snacks. Mealtimes were social occasions when all of the service users were encouraged to sit together in the dining room at tables. Service users were encouraged to help with meal preparation. West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users physical and emotional health needs were considered throughout. EVIDENCE: There was evidence that all of the service users had been signed up with a local GP and that where necessary health issues had been considered. For example a service user who appeared to be gaining weight had been weighed regularly and referred for specialist help. Because service users had not been at the home very long there was no evidence that regular health checks, such as dental and optical appointments were made. The manager was aware of the need to do this now service users were settling in. Detailed healthcare plans and health details were seen within the care records. These documents were similar to the Health Action Plans (HAP) that were a fundamental part of ‘Valuing People’ along with PCP. West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 15 Behaviour charts were completed daily for the service users and the company employed a behaviour therapist to work with, and advise the staff. Medication records were examined. The home used a monitored dosage system supplied by Boots. There had been some problems with ordering, and when auditing the medication each of the service users was working to a different week of their pack. For the last two months staff had not signed medication into the home so this also made it difficult to form an audit trail. The week of the inspection there had been a medication error; a medication had been forgotten. When the error had been identified it had been dealt with correctly and the appropriate people informed. West Drive DS0000069536.V346374.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust polices for that protected service users and supported complaints kept service users safe. EVIDENCE: According to the manager, there had been no complaints received by the home, or about the home, since it opened. The home’s Statement of Purpose contained all the required information about the home’s complaints process. Sampling of the finances of the service users whose care was case tracked suggested that financial records were accurately kept. The home had a robust policy for the safeguarding of adults that was linked to the local policy. All of the staff had received safeguarding training and the manager had referred correctly one incident involving a member of staff and a service user. Staff spoken to were aware of their responsibility when caring for the service users and how to recognise abuse. West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of décor, furnishings and fittings in this home were very good creating a pleasant and homely environment for the service users. EVIDENCE: The home was clean and tidy throughout and in a good state of repair. Each of the service users had their own en-suite bedrooms and were in the process of being encouraged to personalise these. The bedrooms on the ground floor would be accessible to someone with mobility problems. The home benefited from having space and allowed service users the freedom to move around without being in each other’s way. West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 18 When in the home the service users had access to their bedrooms, which could be locked if they wished, a communal lounge, the dining room an activity room and a quiet room which is fitted with snoozelan equipment. Service users could use the kitchen following a risk assessment with the support of a carer and can also use the laundry room with support. At the time of the visit none of the service users had been assessed as able to use the laundry or the kitchen independently, so having these rooms locked did not pose a problem but consideration must be given to this in the future. The garden had been left wild because the company were building a bungalow in the ground next to the home. The plan was to landscape both areas at the same time. This meant that service users could not use the garden easily although one service user was still managing to ride a bike in the garden. Policies were in place regarding infection control. Hand washing facilities were provided appropriately. West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Many of the staff team had benefited from an extended induction while the home was empty and being prepared. EVIDENCE: The staff team that were recruited prior to the home opening had the unique opportunity to train together regardless of their previous qualifications and experience. During this time all the staff completed the LDAF induction programme and further mandatory and specialist training. As previously stated it was noted that the staff and service users interacted positively with one another. Staff included service users in their plans and the resulting atmosphere was relaxed and happy - similar to an extended family. There were 17 staff providing 24/7 care for six service users, on the day of the inspection seven staff were on duty. It was noted that due to the emergency admission on the day of the inspection an extra staff were asked to come on duty that night, to be one to one with the new service user while he settled in. West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 20 There were 11 female and six male staff members, although at the time of the inspection there were no female service users. In line with many other local care services the staff ethnicity did not reflect the ethnicity of the service users. All of the full time staff had, or were enrolled on, an NVQ training course. However at the time of writing less than the suggested 50 of the staff had NVQ. The company had an agreement with us that, as they had a PRM (Provider Relationship Manager), they had the option to store all staff recruitment details centrally away from the home. They had agreed that we could visit at anytime during office hours and without notice. The PRM was contacted and stated that he had plans to do that. However it was expected that proformas were kept in the home that included information that confirmed the staff member had a Criminal Record Bureau check and that references and other checks had been completed prior to taking up the post. The proformas seen had not been completed in sufficient detail and we, and the manager could not be sure that all the necessary checks had been completed on staff before they started work. The operational manager, who had been involved in the recruitment of the staff, believed that the checks had been done and that it was the pro-formas had been poorly completed. A requirement has been made that the manager must have sufficient information to ensure that staff have been vetted correctly. The PRM was also informed. The manager had a detailed account of the training that the staff had undertaken since the home opened but there was no programme for future training. Senior staff had received supervision training and staff were being supervised but it was too early to assess if they were receiving regular supervision. West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home manager was hard working and conscientious but was finding it hard to relinquish some of the care duties and not be ‘all things to all people’. EVIDENCE: When the home was first registered Darren Rawlings was not the manager. Since registration Mr Rawlings, who was proposing to manage one of the other Milbury services in Bedfordshire, successfully became the registered manager. He had therefore had to take on some projects that had been started by his West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 22 predecessor. Mr Rawlings has 16 years experience of working in care and has worked in care management for eight years. Staff spoke very highly of the manager and referred to him as a ‘brick’ and a ‘real support’. However it was apparent during inspection that he was finding it hard to detach sufficiently from the ‘hands-on’ work at times to ensure that all the management work was covered. For example had he spent time auditing the work delegated to staff, he would have picked up on some of the things identified at inspection. For example checks that were not carried out within the stated timescales. The managers role would be easier if he had administrative support or access to e-mails and if the staff computer was not used by service users for a period every day. Because the home had not been operational long it was impossible to assess if the home had an effective quality assurance monitoring system in place. It was noted that regular regulation 26 visits were made to the home but staff and service user meetings were not happening regularly. We were also concerned that some of the ‘evidence to show that we do it well’ sections of the AQAA did not accurately reflect what was seen. It was noted that some documents stored in the home had not been accurately recorded or that dates and signatures were missing. However others were of a high quality and included a lot of meaningful information. All records were securely stored and most were kept up to date. Staff and training records showed that the staff team had undertaken training relating to health and safety matters, including fire safety and food hygiene The latest fire check carried out by the fire service had taken place 05.03.07 the manager had been advised that their should be individual plans for the service users. Routine checking of fire appliances and equipment was taking place regularly. The last staff fire drill was18.08.07 and regularly weekly checks had taken place until that date so on the day of inspection the check was 5 days late. It was also noted that the weekly vehicle check was running late. West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 23 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 1 2 2 3 3 4 3 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 3 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 1 2 x LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 2 x x 2 2 x West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 24 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 YA1 Regulation 4&5 Requirement The Statement of Purpose and the Service users Guide must be available in formats suitable to the service users. Care plans must be written with service user involvement and must be signed and dated by the person writing them. The service must be able to provide the evidence that what service users do is what they wish to do. Timescale for action 30/11/07 2 YA6 15(1) 31/10/07 3 YA7 12(3) 31/10/07 4. YA9 13 (4)(b) Service users files should only 31/10/07 include risk assessments that are pertinent to the service user. There must be individual activity 31/10/07 plans for each of the service users that reflects their interests. There must be evidence that service users have had the opportunity to menu plan. For example, pictures of meals from which they can make choices. 31/10/07 5. YA12 YA14 16(2) (m)(n) 16(2)(h) 6. YA17 West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 25 7 YA20 13(2) Staff must ensure that medication procedures are followed correctly and that medication coming into the home is recorded so an audit trail is always available. If pro-formas are to be used as evidence that staff have been recruited successfully they must be fully and accurately completed. This has been agreed with the PRM for the company. 01/10/07 8 YA34 19 01/10/07 9 YA35 18(1)(c) A training record must include training that has been completed and that which is planned for the future. The manager must ensure that all the duties required of a registered manager including auditing the work of others is accurate and complete. All staff must ensure that any documents written are completed accurately and are signed and dated. All health and safety checks are carried out at the stated intervals to ensure the safety of staff and service users. 30/11/07 10 YA38 9 (2) 31/10/07 11 YA41 17 01/10/07 12 YA42 12 01/10/07 West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 26 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 YA2 Good Practice Recommendations The initial assessment must give more detail of the service users interests and pastimes to ensure that this can be continued. Wherever possible information about the home and how it runs should be provided a user-friendly style that suits the service users. Staff should find out more about the leisure facilities and activities available locally. The home should give consideration to providing service users with a computer from their own use so they do not have to be in the staff office when using the computer. Consideration must be given to landscaping the garden as soon as possible. An excess of 50 of staff should have a minimum of NVQ level 2. 2 YA8 3 4 YA13 YA14 5 6 YA24 YA32 West Drive DS0000069536.V346374.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI West Drive DS0000069536.V346374.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. 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!