Care Home: Positive Community Care

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What the care home does well The staff team have the experience and knowledge to support residents with mental health needs. The residents commented positively about the staff and the support they receive. Residents` rights and choices are respected and promoted. Care plans are detailed and consider each resident`s individual needs. What has improved since the last inspection? The downstairs bathroom has been updated and refurbished. The staff team are supported to study for an NVQ. Two references and a POVA First check are obtained prior to a new member of staff working in the home. The home had devised a development plan for the home. What the care home could do better: Various documents need to be developed and reviewed such as risk assessments on potential or likely risks posed to a resident or towards others. The fire risk assessment must be separately developed and recorded in more detail and an overall quality assurance report needs to be devised to show how the home has reviewed the care provided in the home and aims and objectives for the forthcoming year. Medication systems need to be more robust in order to ensure the residents health and welfare is not placed at risk. The environment must be homely, clean and welcoming, with the first floor bathroom needing attention. Staffing levels must be monitored to ensure the residents receive the care and support they individually need. The training programme for staff needs to be detailed and provide staff with the skills and information to appropriately support the varied needs of the residents. CARE HOME ADULTS 18-65 Positive Community Care 174 Petts Hill Northolt Middlesex UB5 4NW Lead Inspector Sarah Middleton Key Unannounced Inspection 26th November 2007 09:35 Positive Community Care DS0000027713.V342982.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 Positive Community Care DS0000027713.V342982.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. Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Positive Community Care Address 174 Petts Hill Northolt Middlesex UB5 4NW 0208 621 1724 0208 248 8496 pcc707@aol.com www.positivecommunitycare.co.uk Ms Charmaine Watson-Mattis 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) Mr Leisel Alian Vaiphei Suantak Care Home 9 Category(ies) of Learning disability (9), Mental disorder, registration, with number excluding learning disability or dementia (9), of places Physical disability (1) Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One (1) place for a service user with a physical disability can be accommodated. 9th January 2007 Date of last inspection Brief Description of the Service: Positive Community Care (PCC) is a care home for nine adults with mental health needs and/or a learning disability. The overall aim of the service is to support residents in maintaining and developing their independence and integrating into the community as part of a rehabilitation process, where applicable. Levels of support are defined through individual assessments of need. The home was established in 1997 and initially was two small homes operating side by side, which were later combined into one. A third house (166 Petts Hill which is next to 170) is operated by PCC as a supported living scheme (SLS). The care home’s bedrooms are all singles. Three bedrooms are en-suite. Two bedrooms have been created within the loft space. The home has adequate communal areas including a conservatory and large rear garden. The home is in a residential area, next to a convenience store/petrol station, and is on a bus route. The staff team comprises of a Registered Manager, Deputy Manager, two senior support workers and support workers. The fees range from £500 to £1,000 per week. Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. The inspection visit was from 9.35am-6pm. The term “service user” will not be used in this inspection report. Instead the term “resident” will be used. Resident refers to the people living in the home. The term “we” refers to the Inspector who carried out the inspection. The Registered Manager had completed an Annual Quality Assurance Assessment and this was viewed prior to the inspection. The majority of the residents and one relative had completed postal surveys. Overall feedback was positive. The home had met all of the previous seven requirements made at the last inspection and seven new requirements were made at this inspection. All of the key National Minimum Standards were assessed. What the service does well: What has improved since the last inspection? The downstairs bathroom has been updated and refurbished. The staff team are supported to study for an NVQ. Two references and a POVA First check are obtained prior to a new member of staff working in the home. The home had devised a development plan for the home. Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 6 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. Positive Community Care DS0000027713.V342982.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 Positive Community Care DS0000027713.V342982.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed prior to moving into the home. EVIDENCE: The Registered Manager confirmed that all prospective residents are assessed and encouraged to visit and spend time in the home. Information from the referrer, such as care plan and risk assessment are requested. Information is also sought from healthcare professionals and where possible the resident. An assessment and initial care plan was viewed regarding the most recent resident admitted into the home. This document contained details on the resident’s social, health and personal care needs and how these needs were to be met. The home makes every attempt to devise an initial care plan so that staff can support the new resident safely and appropriately. Positive Community Care DS0000027713.V342982.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): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed and recorded onto a care plan. Residents are empowered to make decisions about their lives. The shortfalls in recording residents’ potential risks could jeopardise the safety and welfare of the residents. EVIDENCE: The home’s pre-admission assessment informs the completion of an initial care plan. Two initial care plans were viewed regarding the residents we case tracked. Evidence was seen that care plans are reviewed on a monthly basis and amended as and when necessary. All care plans are subject to a formal six- month review, where the resident and relatives’ can attend a meeting to discuss the placement and consider any changes in needs. A member of staff spoken with confirmed that residents are involved in the development of care plans. Monthly keyworking meetings also take place and Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 10 this is an opportunity for the resident to consider personal goals and assistance they need to achieve these goals. Topics such as daily living tasks, personal care and cultural needs are also looked at. There was evidence to show that staff record in detail the residents needs and involve the resident wherever possible. Daily records were not viewed at this inspection. The home assesses the level of ability and independence of each resident. Some residents can independently manage their own finances. One resident spoken with confirmed he could go out alone and would let staff know of his plans. There are some residents who need more support and are unable to go out without a member of staff. Residents meetings take place and enable open discussions about the home. Risk assessments were seen and covered a range of areas. Each risk is considered and actions to take along with recommendations are recorded. It was noted that risks had not been assessed for those residents who, on occasion, fail to respond to the fire drills. Furthermore there was no evidence that the risks had been assessed for a resident who self-medicates. This was discussed with the Registered Manager and a requirement was made for this to be addressed. Positive Community Care DS0000027713.V342982.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): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to engage in activities both in the home and in the community. Residents are supported to maintain their personal and family relationships. Residents’ rights are acknowledged and satisfactorily promoted. Overall residents in the home receive a varied and healthy meal provision. EVIDENCE: Residents engage in various levels of activity, dependant on their mental health needs and interests. The home has a separate small building at the end of the garden where activities such as painting take place. Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 12 Each day staff organise different activities for those residents interested and able. Activities might be encouraging residents to gain and develop daily living tasks, such as cooking and cleaning. One resident was seen to go out to visit his family and another spent time watching television. Some residents are reluctant or unable to take part in regular activities. Staff are aware of the need to motivate and encourage some residents more than others. The Annual Quality assurance Assessment stated that the home, along with the other services owned by the same Registered Provider, have set up a football team and residents are able to take part in playing football and meeting others. Day trips are also organised and a holiday had taken place. Various forms of transport are accessed. The home is near to bus routes and train stations therefore public transport is often accessed. Those residents asked said they were able to see friends and relatives in the home. Residents also spend time, in particular at weekends with relatives or friends. Residents confirmed they have keys to their bedrooms and they receive their own personal mail. Staff work mainly alone with the residents. Staff were seen to interact positively with the residents on the day of the inspection. Those residents asked said staff spoke courteously to them. Menus were viewed and each day there is a vegetarian and non-vegetarian menu available. Residents choose the meals they would like to eat and alternative meals eaten are recorded. Each evening a member of staff assist a resident to prepare a main meal for everyone living in the home. Residents commented positively on the food provided in the home and staff said that fresh produce is used in the preparation of meals. The fridge was viewed and contained fresh vegetables. The home is aware that close monitoring of the meal provision is necessary as some of the residents have health issues. The meals provided variation and incorporated culturally appropriate foods. Fridge and freezer temperatures had been taken and were within a safe range. Positive Community Care DS0000027713.V342982.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): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive support to maintain their personal care appropriately. Residents’ health needs are recorded and managed satisfactorily. The shortfall in administering medication as prescribed could place the welfare of the residents at risk. EVIDENCE: Overall residents are able to manage their own personal care needs. Some residents need encouragement and guidance to maintain good personal care. All residents have a GP and medical appointments are recorded along with any treatment or advice given from these appointments. The residents’ weights are checked and records of these were seen. For those residents who have health issues the Registered Manager is confident this is being managed and monitored by the staff team and healthcare professionals. Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 14 New staff spend the first few days working alongside existing staff to observe good practice when handling and administering medication. A suitably trained professional also provides training. We viewed samples of competency assessments that staff complete. This shows the staff member’s awareness and knowledge of medicines. The Annual Quality Assurance Assessment stated that weekly medication audits take place and this was confirmed during the inspection. Medication is stored in a safe and secure cabinet. A random check on the medication found that there was an additional tablet for Clozapine 100mg. The Medication administration Records did not indicate the reason for this error. This was discussed with the Registered Manager and a requirement was made for staff to be vigilant when handling and administering prescribed medication. Positive Community Care DS0000027713.V342982.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): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives can feel that their views would be listened to and acted upon. Residents are safeguarded from abuse and neglect. EVIDENCE: The complaints procedure was seen in the communal hall. The home has not had any complaints since the last inspection. The Registered Manager acknowledged that a complaints record form should be devised and he will consider implementing this so that if a complaint were received there would be clear documentation in place to track the action taken. Those residents asked said they would feel able to talk to staff if they were unhappy or concerned about an issue. There have been no adult protection investigations or concerns. Some staff would benefit from receiving refresher training on this subject, (see standard 35 for further details). The home has a copy of the Local Authority’s adult protection policy and procedure. Those staff asked said they would report any adult abuse concerns to the Registered Manager. The Registered Manager explained that all financial transactions are recorded and where possible receipts are obtained. We saw a resident sign a book Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 16 stating the amount of money he had requested from staff. Residents’ money is counted weekly and there have been no errors. Residents’ money was not counted at this inspection and will be looked at during the next inspection visit. Positive Community Care DS0000027713.V342982.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. Residents live in a home that is comfortable and safe, with the exception of the first floor bathroom. The home is sufficiently clean and hygienic. EVIDENCE: We toured the home and viewed a sample of rooms. Overall the home is satisfactorily maintained. The two bathrooms had been updated and refurbished to a good standard. The first floor bathroom had white paint over the flooring and the seal around the bath was mouldy in places. This was brought to the attention of the Registered Manager, who stated that this room was due to have new flooring. A requirement was made for this room to be maintained to a good standard. Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 18 One resident showed their bedroom and this was seen to be spacious and personalised. The resident commented positively on their bedroom. The laundry is located in a small cupboard under the stairs and residents are supported to carry out this task as and when needed. The home does not have a dedicated cleaner and staff commented on the amount of time they spend cleaning the house. This should be reviewed by the Registered Manager to ensure time spent cleaning is not time taken away from supporting the residents. Overall the home was clean, tidy and free from unpleasant odours. Positive Community Care DS0000027713.V342982.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent and supportive staff team supports the residents. Robust recruitment procedures are in place and safeguard the residents. The training programme needs to ensure staff are adequately trained to meet resident’s needs. EVIDENCE: The staff team is a mixture of ages, experience and gender. The Registered Manager is aware that a minimum of fifty percent of the staff team needs to have an NVQ. Two members of staff are waiting to commence studying for this qualification. The Deputy Manager has an NVQ level 3 and one senior worker has an NVQ level 2. We were satisfied that the staff team have the opportunities to develop and gain new skills and knowledge. The rota was viewed. This has recently changed due to the resident vacancies currently in the home. There are times where there is one member of staff Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 20 working on the morning shift. Previously this shift had two members of staff working together. The Registered Manager had informed the staff team of these changes and is hopeful that this is a short-term arrangement until the resident vacancies are filled. Two members of staff expressed concerns regarding not working the allocated hours they had initially been contracted to work, as some of their hours had decreased. Although some of the residents are independent and stable, the Registered Manager and Registered Provider need to ensure the care, support and encouragement of all the residents is maintained. This could prove difficult to do if there are many times where there is only one member of staff working in the home. A requirement was made for the staffing levels to be closely monitored and where necessary increased to enable staff to support the residents and carry out their tasks to the best of their abilities. Discussions took place with the Registered Manager regarding having a teambuilding day. This could be where the staff team consider the home’s aims and objectives and look at the roles within the staff team. Staff have different opportunities to meet, usually at team meetings. A meeting has been arranged in December to reflect on the past year. However, due to rota changes and staff being affected by the staffing hours it was recommended that a separate team building day might prove beneficial for the whole staff team and consequently the residents. The Registered Manager will consider implementing this. Two staff employment files were viewed. These contained the required documentation, such as completed application form, Criminal Record Bureau Checks, health declaration and two references. One staff file did not contain a recent photograph. This was highlighted to the Registered Manager who will follow this up and obtain one. Discussions took place with the Registered Manager regarding ensuring that the references stated on the application form correspond to the references actually obtained. The references seen were from the most recent employer, as this had been a previous requirement. The induction for new members of staff was viewed. This covers a range of subjects, such as health and safety, medication, policies and procedures. New staff spend time working alongside existing members of staff observing how they work and interact with the residents. Samples of training files were viewed. The individual training record only recorded the training the member of staff had attended this year and therefore it was not clear if the member of staff was up to date with their mandatory training. Moving and handling, fire awareness, health and safety and protection of vulnerable adults were out of date on those files viewed. This was discussed with the Registered Manager, as training records need to accurately record the training attended and provide evidence that staff are up to date with all of the required training. Additional, more specialist training also needs to be accessed in order to meet the individual resident’s needs. Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 21 Discussions took place regarding the benefits of devising an overall training plan, so that at a glance the whole staff team’s training can be viewed. A recommendation was made for this to be developed and used. A similar requirement had been made at the last inspection regarding training records, however due to the different nature of the shortfalls a new requirement was made for this area to be addressed. The Mental Capacity Act 2005 was discussed. The staff team have not received information or training on this legislation or how to implement it. The Registered Manager has some information on this subject that needs to be shared with the staff team. A recommendation was made for this shortfall to be addressed. Positive Community Care DS0000027713.V342982.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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from living in a home that is run in a satisfactory manner. Residents’ views are taken into account and these views need to be used to inform a quality review report. The lack of a detailed fire risk assessment could pose a risk to the safety of the residents. Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home is well managed with the Registered Manager familiar with the running of the home and the needs of the residents. He has just completed an NVQ level 4 and Registered Managers Award. Feedback was positive regarding the approachability of the Registered Manager. The home has monthly Regulation 26 visits and reports were available and seen. Twice a year the views of the residents are sought. Surveys ask various questions on areas such as residents the staff, home and meal provision. Discussions took place as to the possible benefits of also obtaining the views of relatives, friends and professionals. The Registered Manager will consider implementing this as an additional way to obtain views on the home. There is a newsletter available that provides information about the services the Registered Provider owns. The Registered Manager currently has no overall quality assurance summary or report that brings together all the various aspects of reviewing the care being provided. A requirement was made for this report to be devised and available for residents and inspection visits. Samples of maintenance records were viewed. Fire drills had been held regularly, but these records did not record the names of the staff that attend the drills. This was brought to the attention of the Registered Manager who will record this in future drills. As noted earlier not all residents respond to the fire drills and this needs to be documented. Fire equipment had been recently inspected and serviced. It was noted that in the overall environmental risk assessment some areas relating to fire had been assessed. This should be recorded in more detail on a separate fire risk assessment and a requirement was made for this to be addressed. One resident who spends time in his room likes to have the door propped open. The door needs to be fitted with door releasing equipment that responds to the fire alarm being set off. Until this is fitted, this door must remain closed. The Registered Manager confirmed that he would inform the resident and other staff of the need to keep the door closed. Other servicing records, such as Portable Appliance test and Legionella were up to date. The Gas Safety Record was out of date and subsequent to the inspection a copy of the new Gas Safety Record was seen. Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 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 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 2 x 3 x 2 x x 2 x Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 25 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. 1. Standard YA9 Regulation 13(4)(c) Requirement Timescale for action 17/12/07 2. YA20 3. YA24 4. YA33 5. YA35 To safeguard residents, detailed risk assessments, on all potential risks must be recorded and reviewed on a regular basis. 13(2) In order to protect the residents’ health and safety, all medication must be administered as prescribed. 23(2)(d) To provide residents with a homely and clean environment to live in, the 1st floor bathroom must be updated and adequately maintained. 18(1)(a) To ensure residents are safeguarded and supported sufficient numbers of staff need to work in the home on each shift. 18(1)(a)(c)(i) The training programme needs to be detailed and offered regularly to provide the staff team with the skills and knowledge they need to support residents appropriately. 27/11/07 03/03/08 31/01/08 30/04/08 Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 26 6. YA39 24(2) An overall short report needs to be developed so that residents can easily read and be confident that the home continuously reviews and improves the care being offered. To protect the residents’ health and safety, a detailed fire risk assessment must be completed. 31/03/08 7. YA42 23(4)(a) 04/01/08 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. 2. 3. Refer to Standard YA33 YA35 YA35 Good Practice Recommendations It is recommended for a team building/review day to be organised. It is recommended for an overall training plan for the whole staff team to be developed. It is recommended for staff to receive information and training on the Mental Capacity Act 2005. Positive Community Care DS0000027713.V342982.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection 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 Positive Community Care DS0000027713.V342982.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. 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