Care Home: 2 Dunstans Drive

Similar services:

• Hillview Farm
• Dalewood Respite Care
• Orchard,The
• REACH Upton Court Road
• Fairways
• Treloar College
• Kestrel House, St Anne`s Opportunity Centre,
• Pinta

What the care home does well The home provides a good standard of personal and health care support for the people who receive a service. Communication passports are used to maximise people who use the services` choice and involvement. The staff were observed to be relaxed, friendly and professional with people who use the service, at all times. People who use the service have the opportunity to participate in a wide range of activities. Clients are treated equally and their diverse needs are catered for. A relative commented in the survey, `they provide my son with a friendly atmosphere, treating him as an able bodied person where possible. I feel my son is well looked after and has definitely progressed since living in the home` What has improved since the last inspection? Staff are starting to receive regular supervision; the kitchen has been refurbished; a door for the shower has been ordered; and all the risk assessments have been reviewed. What the care home could do better: All staff should receive epilepsy training; the satisfaction surveys sent by the organisation to staff and relatives should be designed to provide information about the individual homes i.e. Dunstans Drive; people who use the service should be weighed regularly; new appointments made for people who use the service who missed appointments with health professionals; ensure a medication review is included in the check list when people who use the service have health reviews; record health appointments in a clearer way to enable staff to keep a check on what appointments need to be made and if people who use the service have attended; two care plans should be brought up to date in a person centred format; internal reviews of the care plans should take place in between the annual reviews; and monthly summaries of the daily notes should be made. CARE HOME ADULTS 18-65 2 Dunstans Drive Winnersh Wokingham Berks RG41 5EB Lead Inspector Robert Dawes Unannounced Inspection 14th November 2007 10:00 2 Dunstans Drive DS0000051745.V353020.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 2 Dunstans Drive DS0000051745.V353020.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. 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2 Dunstans Drive Address Winnersh Wokingham Berks RG41 5EB 0118 979 5362 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) caroline.bilsby@new-support.org.uk www.new-support.org.uk New Support Options Ltd Mrs Caroline Lisa Bilsby Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th September 2006 Brief Description of the Service: 2 Dunstans Drive provides accommodation and personal care for four adults who have learning and associated physical disabilities. The accommodation is a purpose built bungalow and is sited on a residential estate. Toynbee Housing Association Group owns the building and the care is provided by New Support Options. The home is situated approximately ten minutes from Wokingham and Reading town centres; all community facilities are easily accessible with shops within walking distance. The home has its own vehicle and there is good access to public transport. The Registered Manager confirmed in November 2007 that the current fees charged for each service users care is £1364.52 per week. Additional charges are made to the service users or their representatives for chiropody services; hairdressing, toiletries, clothing; day services activities and various community activities. The home has a statement of purpose that describes the service provided. Access to any reports published by the Commission for Social Care Inspection about the service provided are available in the home. 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced site visit, which took place during the day on the 14th November 2007. The Annual Quality Assurance Assessment, two relatives’ questionnaires and one Health Professional’s questionnaire were returned to the inspector before the site visit. These, together with the site visit, were the main sources of information for the key inspection. During the site visit the inspector interviewed the manager and two members of staff; toured the premises; looked at records; case tracked; and observed the interaction between clients and staff. No service users were spoken with because of communication difficulties. There are currently three people who use the service resident in the home. Twenty three standards were assessed during the site visit of which twenty one were met and two were nearly met. Five recommendations were made. What the service does well: The home provides a good standard of personal and health care support for the people who receive a service. Communication passports are used to maximise people who use the services’ choice and involvement. The staff were observed to be relaxed, friendly and professional with people who use the service, at all times. People who use the service have the opportunity to participate in a wide range of activities. Clients are treated equally and their diverse needs are catered for. A relative commented in the survey, ‘they provide my son with a friendly atmosphere, treating him as an able bodied person where possible. I feel my son is well looked after and has definitely progressed since living in the home’ 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 6 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. 2 Dunstans Drive DS0000051745.V353020.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 2 Dunstans Drive DS0000051745.V353020.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): Number 2. People who use the service experience good quality outcomes in this area. Prospective people who use the services’ individual aspirations and needs are assessed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No person who uses the service has been admitted to the home for several years. There is a detailed admission policy and procedure in place. 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 6, 7 and 9. People who use the service experience good quality outcomes in this area. All the people who use the service have care plans which are reviewed annually. To ensure the people who use the services’ changing needs and personal goals are properly reflected in the care plans, two plans need to be brought up to date in a person centred format, internal reviews of the care plans should take place in between the annual reviews and monthly summaries of the daily notes should be made. The home works hard to enable service users lead as independent a life as possible and make decisions about what they do and how they are cared for. A variety of communication tools and techniques are used to enable people who use the service communicate their individual choices. This judgement has been made using available evidence including a visit to this service. 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 10 EVIDENCE: All three people who use the service have individual care plans but only one plan has been up dated in a person centred format. The plans have been reviewed annually using the ‘PATH’ format. The organisation is introducing an ‘Essential Life Style Plan’ format to review care plans, which will be more detailed and include objectives and goals. A relative commented in a survey ‘at a review meeting with the staff we discussed providing R with computer aided equipment to help him communicate. This has not been actioned’. The inspector recommended six monthly internal reviews would enable the home to check on the progress of goals made at annual reviews and updated to reflect changing needs. Daily notes are made of the people who use the services’ activities, health and personal care but monthly summaries are not made to enable staff to monitor the changing needs of the people who use the service. Key workers for the people who use the service are to be reintroduced after a period of staffing difficulties. The regular service users’ meeting records and individual files showed that service users are involved in making decisions about their daily lives, i.e. what they would like to do and where to go on holiday. In reply to the question in the relatives’ survey ‘does the care service support people to live the life they choose?’ the relatives replied ‘usually’. In reply to the question in the health professional’s survey ‘does the care service support people to live the life they choose?’ the health professional replied ‘usually’. All of the service users have significant difficulties in communication. The manager and staff use a range of communication techniques to ensure the people who use the service communicate their views and make decisions about their lives. A speech and language specialist has helped develop communication passports which are kept by people who use the service at all times. The manager has been unable to find advocates for the people who use the service. The people who use the service have very limited capabilities but are encouraged and enabled to be as independent as possible. The recently refurbished kitchen has a sink and a hob, which can be lowered to enable the people who use the service, participate in food preparation. Appropriate risk assessments are in place. 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 12, 13, 15, 16 and 17. People who use the service experience good quality outcomes in this area. People who use the service take part in a wide range of appropriate activities which reflect their diverse needs; they participate in the local community and are enabled to keep in touch with their families and friends; their rights are respected and responsibilities recognised in their daily lives; and are offered a healthy diet and enjoy their meals. The organisation is promoting diversity and equality. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The activity program is very varied both in the local community and in house. Activities include hydrotherapy, music (each person who uses the service has their favourites i.e. Max Bygraves and Abba), football matches, line dancing club at the Friday night project, shopping, No 1 club, cinema, Karaoke club, parties at other homes, day services three times a week which includes swimming, Thames Valley adventure playground, bowling, pubs and eating 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 12 out. People who use the service choose which activities they wish to participate in. All three people who use the service attend a local church. During the summer months staffing difficulties has restricted the opportunities for people who use the service to access facilities in the community. This should improve when a new member of staff starts work in the home and another member of staff returns from maternity leave. There will then be three drivers, including the manager, available to drive the adapted vehicle and take people who use the service out to activities. The organisation is promoting diversity and equality by appointing a diversity lead person; publishing a diversity newsletter; providing ‘diversity and equality training opportunities for staff; and ensuring service users’ cultural needs are addressed i.e. taken to cultural events and eating food that reflects their culture. Family links and friendships are positively encouraged i.e. some of the service users visit their family homes with the assistance of members of staff; and one person who uses the service is assisted to send a letter regularly to his parents and brother. Service users were observed to have unrestricted movement around the home, except other people’s bedrooms. Service users can choose to be alone. Service users help with food preparation and are present when cleaning and laundry takes place. A very positive and respectful interaction between staff and people who use the service was observed. Menus seen were nutritious and varied. People who use the service are provided with meals they like and are offered a choice. Staff meeting records showed the manager ensures meal times are flexible to suit the people who use the services’ schedules. People who use the service who need help to eat are assisted appropriately and provided with appropriate eating aids. Care plans included suitable and unsuitable foods; and eating, drinking and swallowing guidelines. 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 18, 19 and 20. People who use the service experience good quality outcomes in this area. People who use the service receive personal support in the way they prefer and require; and their physical and emotional health needs are generally well met. Regular weighing, new appointments made for people who use the service who missed appointments with health professionals and ensuring a medication review is included in the check list when people who use the service have health reviews need to take place. People who use the service are protected by the home’s medication procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From conversations with members of staff and observations of the service users during the site visit it was evident that service users do receive flexible personal support. Staff meeting records showed the manager ensures staff provide flexible personal support to the people who use the service. The relative of a person who had recently died after a short illness was very complimentary about the standard of care provided by the staff. 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 14 A relative commented in a survey ‘his personal hygiene and cleanliness of his clothing are excellent’. Communication passports are used to enable staff to communicate as effectively as possible with the people who use the service. In response to the questions in the relatives survey ‘does the care service respect individuals’ privacy and dignity?’ and ‘does the care service respond to the different needs of individuals?’ both relatives replied ‘usually’. Records showed the people who use the service receive regular dental, eye and health checks with the GP. There was also evidence that service users are receiving specialist support from epilepsy services, psychiatrics and occupational therapists. However, there was no record of the people who use the service being weighed regularly; further appointments had not been made for a person who had missed a dental appointment and another person who had missed an appointment with an optician; and medication reviews are not included in the checklist when health checks take place. None of the people who use the service had pressure sores. In response to the question in the relatives survey ‘are your relatives’ health care needs met by the care service?’ both relatives replied ‘usually’. In response to the question in the health professionals survey ‘does the care home give the support or care to your clients that you expect?’ the health professional replied ‘usually’. None of the service users self-administer their medication. The medication administration records were in order. Sufficient staff have received medication training to cover all the shifts. Appropriate medication policies and procedures are in place. The home does administer controlled drugs and complies with the policy and procedures for storing and administering controlled drugs. A pharmacist visited the home in January 2007 to inspect the storage, receipt and administration of medication and found the home was complying with the homes policies and procedures. 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 22 and 23. People who use the service experience good quality outcomes in this area. People who use the service feel their views are listened to and acted on; and are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a comprehensive complaints procedure in place. The people who use the service have very limited verbal skills and would find it difficult to complain directly. Staff are clear on observing behaviour and interpreting its meaning. No complaints to the home or the Commission, about the care of the people who use the service, have been made since the last inspection. In response to the question in the relatives’ survey ‘has the care service responded appropriately if you or the person using the service have raised concerns about their care?’ one relative replied ‘always’ and the other relative replied ‘usually’. Staff have received training in safeguarding younger adults. No allegations of abuse have been made to the Commission since the last inspection. A safeguarding younger adults’ policy is in place. In discussions with some members of staff it was evident that they had good understanding of the need to protect service users from the risk of abuse and whom they should report any issues of concern to. 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 16 Each service user has a bank account. Two signatures are required to withdraw money from the accounts. No service user manages his or her own finances. Service users’ personal money is kept in individual tins in a secure facility in the manager’s office. Records of all transaction are kept and audited by a person from outside of the home annually. The home has appropriate policy and procedures for handling clients’ personal money. 2 Dunstans Drive DS0000051745.V353020.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): Numbers 24 and 30. People who use the service experience good quality outcomes in this area. The home is comfortable, spacious, safe and well maintained. The home is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well furnished, decorated and maintained. The kitchen has recently been refurbished, including a ‘drop down’ sink and hob to enable people who use the service to participate in the preparation of meals. A new shower door has been ordered. A maintenance programme, identifying areas of the home that need decorating and carpets that need replacing, is in place. It is sufficiently spacious to enable the people who use the service to move easily around the home in their wheelchairs. 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 18 The home has the necessary aids and adaptations to respond to the individual needs of the people who use the service. The home is clean and hygienic. A relative commented in the survey ‘ they keep a clean and safe home’. 2 Dunstans Drive DS0000051745.V353020.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): Numbers 32, 34, 35 and 36. People who use the service experience good quality outcomes in this area. An effective and competent staff team who receive a broad range of training support the people who use the service fairly, without discrimination and in a caring manner. The organisation operates a thorough recruitment procedure. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff interviewed demonstrated a good understanding of the conditions and needs of the service users. Out of the nine permanent care staff, two have achieved a NVQ 2 or above in care and three are currently studying for the qualification. In response to the questions in the health professionals survey ‘do the care staff have the right skills and experience to look after people properly?’, ‘does the care service meet the different needs of people?’ and ‘do you feel the care home meets the needs of your clients?’ the health professional replied ‘usually’. The people who use the service appeared relaxed and happy. 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 20 A relative commented in a survey, ‘they provide my son with a friendly atmosphere, treating him as an able bodied person where possible. I feel my son is well looked after and has definitely progressed since living in the home’. No new member of staff has started work in the home since the last inspection. Recruitment records are kept at the organisations head office. These records have been assessed during key inspections of other services and found to be compliant with the requirements of the regulations. All new staff undertake an induction training programme including a five day course titled ‘our approach’ which includes topics such as anti-discriminatory practice, values and attitudes and how the organisation expect the people who use the service should be cared for. All staff have received basic training and training in key areas of their work such as safeguarding younger adults, anti discriminatory practice, first aid, person centred planning, values and attitudes and effective communication. None of the care staff have attended an epilepsy training course. Refresher training of key areas of work takes place. Regular supervision is now taking place. Regular bank staff also receive supervision. Annual appraisals are to be scheduled. 2 Dunstans Drive DS0000051745.V353020.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): Numbers 37, 39 and 42. People who use the service experience good quality outcomes in this area. People who use the service benefit from a well run home; their views underpin all self-monitoring, review and development by the home; and their health, safety and welfare are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is qualified, competent and experienced to run the home. She undertakes periodic training to improve her knowledge and skills. Staff described the manager as supportive, approachable and clear in how she wants the clients cared for. 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 22 The organisation ensures an effective quality assurance and monitoring system operates in the home through regular staff and service users’ meetings taking place; a representative of the organisation visiting the home every month to undertake an inspection of the quality of care being delivered; and relatives and staff completing an annual anonymous satisfaction questionnaire. The satisfaction questionnaires that are sent to relatives and staff are not specific to the individual care homes. The inspector recommended the surveys are designed to provide information about the individual homes i.e. Dunstans Drive in order that the success in achieving the aims and objectives of the statement of purpose of the home can be measured. A development plan is produced annually. Records showed all health and safety checks and inspections are up to date and completed as required. Necessary health and safety policies and procedures are in place. The home’s fire risk assessment was last reviewed in May 2005. It is recommended that it is reviewed annually. All the service users’ files contained appropriate risk assessments and had been reviewed regularly. All the staff have received the necessary health and safety training including first aid. 2 Dunstans Drive DS0000051745.V353020.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 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 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 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 2 3 X 3 X 3 X X 3 X 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA6 Good Practice Recommendations To ensure the people who use the services’ changing needs and personal goals are reflected in the care plans, two care plans should be brought up to date in a person centred format; internal reviews of the care plans should take place in between the annual reviews; and monthly summaries of the daily notes should be made. People who use the service should be weighed regularly; new appointments made for people who use the service who missed appointments with health professionals; ensure a medication review is included in the check list when people who use the service have health reviews; and record health appointments in a clearer way to enable staff to keep a check on what appointments need to be made and if people who use the service have attended. All staff should receive epilepsy training to have up to date knowledge and skills to respond as effectively as possible DS0000051745.V353020.R01.S.doc Version 5.2 Page 25 2 YA19 3 YA35 2 Dunstans Drive to any person who suffers from an epileptic seizure. 4 YA39 The satisfaction surveys sent by the organisation to staff and relatives should be designed to provide information about the individual homes i.e. Dunstans Drive, in order that the success in achieving the aims and objectives of the statement of purpose of the home can be measured. The home’s fire risk assessment is reviewed annually to identify any potential risks to the people who use the service. 5 YA42 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 2 Dunstans Drive DS0000051745.V353020.R01.S.doc Version 5.2 Page 27 - 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!