Care Home: Aldeburgh House

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What the care home does well The home provides a service that respects people`s individuality. Interactions observed between staff and people living in the home were friendly. Staff know service users very well and were able to provide support in a way that met their needs and wishes. Aldeburgh House continues to provide opportunities for personal development and a fulfilling lifestyle. There was a good programme of activities available, and people were seen coming and going through out the day of the site visit.The home provides a comfortable environment for the people living there; the bedrooms reflect individual tastes, and showed evidence of a variety of personal possessions. Visitors to the home are made welcome and the people living there are supported and encouraged to maintain contact with their families and friends. What has improved since the last inspection? Since the previous inspection the home`s Statement of Purpose has been reviewed and updated, and now provides prospective people moving to the home with the necessary information they would require. Staff training has been improved to ensure that all staff now have training in adult protection issues. What the care home could do better: The home`s care planning process needs to be further developed to ensure that they adequately reflect the needs of the people living in the home, and provide staff with the necessary information to enable them to met people`s needs. The registered person must ensure that there is a mechanism in place for admitting new people into the home, which adequately assesses their needs before any admission takes place. Provision needs to be made to ensure that people living in the home and those supporting them are not placed in a vulnerable position by the home`s practice relating to the management of peoples money. The home`s quality assurance process needs to be developed to ensure that it reflects the views of people living in the home, and other interested stakeholders. The training of staff needs to ensure that all staff have the necessary training they require to carry out their roles safely and effectively. CARE HOME ADULTS 18-65 Aldeburgh House 66 Seaview Avenue West Mersea Colchester Essex CO5 8BX Lead Inspector Neal Cranmer Unannounced Inspection 13th May 2008 09:00 Aldeburgh House DS0000050959.V364306.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 Aldeburgh House DS0000050959.V364306.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. Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aldeburgh House Address 66 Seaview Avenue West Mersea Colchester Essex CO5 8BX 01206 384392 01206 386659 aldeburgh@consensussupport.com www.concensusupport.com Consensus Support Services Ltd 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) Mrs Odette Turner Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 8 persons) 12th June 2007 Date of last inspection Brief Description of the Service: Aldeburgh House is a home providing care and accommodation to 8 adults with learning disabilities. Previously owned by Aitch Care Homes Ltd, the home was first registered in March 2004. Aldeburgh House is now part of Consensus Health Care following a take over of Aitch Care Homes in late 2005. The home is a large two-storey property in a residential area close to the sea front in West Mersea, about 10 miles from Colchester. The building has been modernised to provide accommodation in single rooms with en-suite facilities. The home does not have a passenger lift, although accommodation for those with mobility needs is available on the ground floor. There are enclosed, wellmaintained gardens and the home is close to the island facilities. Fee’s for residing in the home are between £1.442.00-£2.619.00. There are no additional charges made for residing in the home. This information was provided by the registered manager on the day of the site visit to the home. Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star. This means the people who use this service experience good quality outcomes. This report follows a key unannounced inspection of the home, which took place on the 13th May 2008. The report has been written using accumulated evidence gathered prior to and during the site visit, including the home’s ( AQAA) Annual Quality Self Assessment. The registered manager and their deputy were present throughout the inspection. This inspection included discussions with residents, the registered manager and members of the care team. A tour of the premises was undertaken during the course of the inspection, which included viewing of residents’ rooms, bathing and toilet facilities, communal areas and gardens. A range of records were sampled, and most were in order. As part of all inspections carried out from the 5th of May to the 16th of May 2008. Nationally the Commission for Social Care inspection was carrying out a thematic probe. A Thematic Probe is how the Commission gathers additional information on a particular theme, the theme on this occasion being safeguarding. Evidence relating to the thematic Probe on safeguarding can be found in the main body of this report under outcome group 22 & 23 Concerns, Complaints and Protection. What the service does well: The home provides a service that respects people’s individuality. Interactions observed between staff and people living in the home were friendly. Staff know service users very well and were able to provide support in a way that met their needs and wishes. Aldeburgh House continues to provide opportunities for personal development and a fulfilling lifestyle. There was a good programme of activities available, and people were seen coming and going through out the day of the site visit. Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 6 The home provides a comfortable environment for the people living there; the bedrooms reflect individual tastes, and showed evidence of a variety of personal possessions. Visitors to the home are made welcome and the people living there are supported and encouraged to maintain contact with their families and friends. 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. Aldeburgh House DS0000050959.V364306.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 Aldeburgh House DS0000050959.V364306.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 and 2. Quality in this outcome area is adequate. People choosing to live at Aldeburgh House receive sufficient information about the home to enable them to make an informed choice about the home’s ability to meet their needs. People choosing to live in the home cannot be assured that their needs will be assessed prior to them moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s Statement of Purpose was reviewed and now provides the necessary information including: the qualifications of the provider and registered manager, the number of staff in post, the client group for which the home is registered, including the age range, facilities and service s provided by the home.The Statement of Purpose is next due for review in January 2009. The home’s procedures were inspected in relation to the admission of people into the service. The procedure was laid out in the home’s Statement of purpose. At the time of this inspection visit no persons had been admitted to the home during the period since the previous inspection and therefore it was not possible to inspect and review the practice procedures. The current Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 9 manager however demonstrated a sound understanding of the practice principles associated with the admission procedure. Aldeburgh House DS0000050959.V364306.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, and 9. Quality in this outcome area is adequate. People living at Aldeburgh House do not benefit from the current care planning system in place, however they are supported to make decisions about their lives and to take risks within their capacity to understand. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One plan of care was case tracked as part of the case tracking process, this plan although written in a person centred way was not easy to follow. The registered manager spoke of the care planning process in Aldeburgh House currently going through a redevelopment phase, the emphasis of which will be to end up with care plans that are entirely individualised as opposed to being a ‘one size fits all’ approach. The home’s AQAA stated that they plan to develop the care planning system to make it more people led and to continue to support them with realistic and relevant goals that they have set for themselves. Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 11 There were no risk assessments in place, and further discussion with the manager indicated that these had been removed from all files for the purpose of being reviewed. People living in the home spoken with spoke positively about the support they received from their carers, both were aware of who their key workers were and of how much they enjoyed doing things with them. Discussion with people living in the home, staff and from observation indicated that staff interacted well with them, and that they supported people to make choices. Staff spoken with were able to demonstrate that routines within the home are flexible. People living in the home spoke of being free to choose when they went to bed in the evening and when they got up in the morning, and mealtimes were flexible to facilitate people’s activities throughout the day. Aldeburgh House DS0000050959.V364306.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, 15, 16 and 17. Quality in this outcome area is good. People living at Aldeburgh House have opportunities to partake in activities that are appropriate to their needs and they are supported to access local community facilities. The home furthermore ensures that people living there are supported to build and maintain relationships with their families. People living in the home are provided with a balanced, nutritional and varied diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were opportunities provided for people to attend activities that promote citizenship and self- esteem, these included attendance at further education classes, which four people were attending. At the time of the site visit none of Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 13 the people living in the home were in any form of paid or voluntary employment, although the manager spoke of being in the process of consulting with Mencap regarding work placements. People living in the home are encouraged participate in community based activities, and two of e spoken with spoke of regularly visiting the pub, attending gateway clubs, visiting the theatre, attending leisure world, to play bowls and football, going to car boot sales, and going fishing. People living in the home are supported to maintain links with their families and friends, and key workers support them to do so through the sending of cards and letters. The home has a portable telephone and people are supported to make and receive calls in private. The home operates an open door policy on the receiving of visitors The home supports people to use community services, in a similar manner to anyone else living in the community. For example all of the people living in the home have their own bank accounts from which they are able to access their money by card using a personal PIN number. As noted at the last inspection for some people this may only be done with support from staff, and it was recommended that this only take place following a risk assessment having been undertaken. To date no such assessment has been undertaken, and there is no policy in place to protect either the people living in the home or the staff supporting them. Cash held in the home was checked in respect of two people and was found to be accurate and well recorded. People living in the home are supported and encouraged to be involved in the planning of the home’s menus. They are supported to do this by the use of ‘Picture recipes’ the menus seen were varied and nutritious and included at least two choices for all meals and evidence of fresh fruit being available was seen. People living in the home are supported to assist with the preparation of meals, and take an active part in shopping for the home’s stores. On the day of the visit one of the people was seen arranging to go out food shopping, and when spoken to later in the day they confirmed that this was something they often did. We were invited to join people for lunch, and the interactions seen during this time between people and staff were positive and genuine. The whole meal took place in a pleasant and relaxed atmosphere. Two of the people living in the home when spoken to later in the day stated that the meals provided were nice. Aldeburgh House DS0000050959.V364306.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 and 20 Quality in this outcome area is good. People living in Aldeburgh House receive personal support that meets their needs, and the home has in place systems to ensure the safe administration of medication and the protection of people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Based upon discussion with people living in the home, staff and from observation, the language, tone and volume of communication was supportive and appropriate. All of the care staff spoken with stated that the home is relaxed and was now felt to be much more person centred. Positive examples of people’s rights and dignity being respected were seen such as knocking on people’s doors, and during the lunchtime meal asking people about their wishes regarding what they wanted to eat. Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 15 All of the people living in the home are registered with a General Practitioner, and healthcare needs were adequately maintained. The home’s AQAA states that people are supported, by their key workers to attend medical appointments within the community as appropriate. These include visits to dentists, chiropodists and audiologists. The home operates a Monitored Dosage System (MDS ) for the administration of people’s medicines. All medicines held in the home at the time of the inspection were stored appropriately. The home was at the time of the inspection maintaining medicines of a controlled nature and the storage and recording in relation to these medicines was in order. All records sampled were in order and there was not any evidence of any gaps or omissions found. The home’s AQAA states that all staff involved in the administration of medicines are expected to have a basic knowledge of what medication they are giving and of any adverse effects they may have and how to deal with them. Staff administering medicines only do so following training from the system’ s provider, in addition to this training they are also subjected to periodic observed assessment by the home’s manager. Aldeburgh House DS0000050959.V364306.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 and 23. Quality in this outcome area is good. People living in Aldeburgh House have access to an effective and understandable complaints procedure, which ensure that their concerns are listened to and the home operates and practices procedures to protect the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s AQAA states that people are encouraged to voice any concerns that they may have to staff or management, and this may either be during home meeting or in private if preferred, it goes on to state that any complaints will be dealt wit promptly in an open an honest manner, through the correct channels. Discussion with one service user indicated that they were aware of who they should speak to if they had any concerns or complaints. There have been no formal complaints received during the period since the previous key inspection. The internal policy and procedure, and a version applicable for the needs of the people living in the home was available. As mentioned in the summary of this report a thematic probe was being undertaken as part of this inspection. As part of the probe the inspector spoke to the registered manager and staff about their understanding of safeguarding matters. In addition to this a range of records were sampled. The outcome of these discussions and sampling of records are as follows: Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 17 Discussion with the registered manager indicated that they were aware of the pre-employment checks that should be undertaken on staff before their commencement in employments, the managers responses included the need to undertake criminal records bureau (CRB) checks, protection of vulnerable adults 1st checks, obtaining two written references, one of which should be of the most recent employer and checking the application form for any evidence of gaps in employment history. Discussion with staff showed that they were aware of the types of abuse that may take place, e g physical, psychological, financial, sexual and institutional. They were also well aware of how and who they should report any suspicions too, and who were the lead agency in relation to safeguarding issues. Staff also confirmed that the home did have in place policies and procedures regarding safeguarding and whistle blowing. Since the last inspection of the service there have been three safeguarding referrals made, all of which were managed appropriately, with the relevant agencies being notified. Sampling of the home’s staff training matrix indicated that all staff had received training in adult protection. Practice in the home indicates that service users are adequately protected. Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, and 30. Quality in this outcome area is good. People living in Aldeburgh House benefit from a comfortable environment that is well maintained and clean. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises confirmed that the home is kept in good decorative order. The home’s gardens are enclosed, and were easily accessible to the people living in the home, and a small patio area where people could choose to go and sit during good weather was available. All of the bedrooms seen were decorated individually to the taste of the person using the room. One person was pleased to show the inspector their room, and they said how much they liked it. Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 19 All of the rooms seen contained ample evidence of people’s individual personal possessions. On the day of the inspection there were no odours throughout the home, and the carpets and other floor surfaces were all clean. The laundry facility in the home is adequately equipped to meet the needs of the number of people living in the home. The home’s AQAA states that the organisation has put in place a five- year plan for redecoration. A copy of this plan was made available to the inspector to view. The AQAA indicated that the plan will ensure that the views of people living in the home will be taken into account. Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is good. People living in Aldeburgh House benefit from a competent, well trained staff team who receive appropriate supervision. The recruitment procedure ensures that the home provides the safeguards that ensure appropriate staff are employed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs seventeen care staff and of these seven hold a National Vocational Qualification (N.V.Q) at level two, with one being qualified at level three, in addition a further two care staff have commenced the level two award. This equates to 44 of the staff team, and falls just short of the recommended 50 . The recruitment of carers was considered in relation to the method, checks and records obtained to ensure that the recruitment practice is safe for people living in the home. Based upon the sample of three records the recruitment practice was appropriate and the various checks and requirements had been undertaken. Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 21 The home’s AQAA states that when staffing levels fall below an acceptable level due to either sickness, holiday’s or vacancies, then agency staff are called in, although they use the same agency to ensure continuity. Training records sampled indicated that staff had received training in the following mandatory training areas: manual handling, fire safety, health and safety, food hygiene, appointed persons first aid, and adult protection, however the figures relating to staff having received this training varied from 30 for health and safety to 100 for adult protection. In addition to the above mandatory training the following training had been provided by the home: medication administration, managing behaviours that challenge, the administration of buccal diazepam and epilepsy. People do need to be supported by an effective team of carers, and further development is needed to ensure that all staff have the necessary skills and knowledge to meet the needs of people living in the home. Discussion with members of the staff team indicated that they currently receive formal supervision from the manager every six to eight weekly. The manager spoke of the intention for the supervision process to be devolved to include the deputy manager and senior carers, for which they will receive training. Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. Aldeburgh House is efficiently and professionally managed and run in the best interest of the people who live there, and the health and safety of individuals living and working in the home is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager was recruited in 2007, and has extensive experience of working in services for people who have a learning disability. The home’s AQAA states that the manager holds a BSc (Honours) in the Management of Health and Social Care. Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 23 The registered manager is only responsible for the one establishment, and keeps themselves abreast of changes in practice. The home is subject to a quality audit by the registered person, although on inspection this approach appears to be mainly focussed upon the efficiency of the service and organisational objectives. The home maintains systems for the monitoring of health and safety including fire safety, emergency lighting, and portable appliance testing. This monitoring of safety is carried out by a combination of testing and checking on a periodic basis by the home and external contractors. Safety certificates for the following services were checked and seen to be current, portable appliance test report, electrical installation certificate and gas safety certificate. The home maintains a Control of Substances Hazardous to Health (COSHH) folder to reference the safe use of various materials used in the home, thereby ensuring the safety and protection of both people living in the home and those supporting them. Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 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 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 x Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 25 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA7 Regulation 15 (2) Requirement The registered person must provide a care plan based upon the needs of the service users, which is kept under periodic review. To ensure that the assessed needs of the service users are met. Timescale for action 31/08/08 2. YA9 14(1)(2)15(1)(2) The assessment relating to a service user must be kept under review and revised at a time when it is necessary because of changes in circumstances. This is now a repeat requirement from the 31/08/07. 24(1 to5) A quality assurance system is needed that is based upon consultation with service users and their representatives. The results of the quality monitoring and action plan must be sent to the Commission. This is now a repeat requirement from the DS0000050959.V364306.R01.S.doc 31/08/08 3. YA39 31/08/08 Aldeburgh House Version 5.2 Page 26 30/09/07. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Aldeburgh House DS0000050959.V364306.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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