The requester asked for inspection reports for 26 specific adult care homes on the Isle of Man, citing a discrepancy between the government website's promise of public availability and the actual access method. The Department of Health and Social Care responded by sending all requested information, including a sample unannounced inspection report for 17 Kensington Road.
Key Facts
The request covered 26 specific adult care homes including 23 Farmhill Meadows and 17 Kensington Road.
The Department of Health and Social Care provided all requested information without redaction.
The response included a detailed unannounced inspection report for 17 Kensington Road conducted in April 2018.
The requester questioned why reports were not easily visible on the gov.im website despite official statements.
The inspection framework used is based on the Regulation of Care Act 2013.
Data Disclosed
2020-01-14
2020-02-06
411
26
18 April 2018
26 April 2018
21/6/17
22/6/17
Two (2)
(01624) 617409
IM1 1EF
IM1 3EP
Section 37
Original Request
Question 1:
Please can I have all of the following inspection reports as inspected by Registrations and Inspections for the following Adult Care Homes?
23 Farmhill Meadows, 3 Rosebank, 4 Rosebank, Bungalow 1, Bungalow 2 (Thie Ny Aishlish), Bungalow 3 (Cooileen), Bungalow 4 (Thie Granagh), 11 Hutchinson Square, 17 Kensington Road, Glendale, Greenacres, Griffindale House, Hollydene, Spring Meadows, Thie Milan, Thie Ushtey, 1 Glen Darragh Gardens, Darragh House, Mount Rule, Thie My Chree, Shen Valley, Cushag House, Ballajra Care Home, Glenroyd, Ingledene & Rosegarth.
Question 2:
Apparently they can only be obtained by - "The inspection reports for this service can be viewed either by contacting the service or the Registration and Inspection Unit" why is this?
They should be easily available to the public and visible for all to see and states clearly on the gov.im website that all reports are published. The gov.im website states the following 'The inspection process not only ensures that services are continuously improving but that the quality of care is monitored on a regular basis to achieve the best outcomes for anyone using these services. We publish our inspection reports online'.
Data Tables (784)
No
Standard
Requirements/recommendations from
previous inspection
Met/
not
met
1.
Standard 1.1
An easy read statement of purpose should be
developed.
Timescale: September 2017
Met
2.
Standard 1.6
During the admission process, the person being
admitted and / or their representative are
provided with a written contract that includes
details of:
Terms and conditions of residency;
including fees for services not included in
the contract.
Details of notice served, support provided
and timeframes.
Details of services / items provided (such as
newspapers, hairdressing, chiropody etc.)
and if there is an additional charge.
Insurance information for personal
belongings.
Timescale: October 2017
Met
3.
Standard 4.1
Staff must complete annual refresher training on
safeguarding adults.
Timescale: Immediate
Not
met
4.
Standard 4.5
The home must have a policy and procedure
specific to physical intervention and restraint.
Timescale: November 2017
Met
5.
Standard 4.10
Staff must receive fire safety training annually.
Timescale: Immediate
Met
6.
Standard 4.10
Emergency lighting checks to be carried out
monthly.
Not met
Carried over June 2017
Timescale: Immediate
Met
7.
Standard 4.11
1. Staff should sign to acknowledge that they
agree with their responsibilities regarding health
and safety in the home.
2. The health and safety inspection and audit
checklist should have a completed action plan.
Met
Met
Requirements/recommendations from
previous inspection
Timescale: August 2017
8.
Standard 4.12
Staff must receive training on infection control.
Timescale: August 2017
Not
met
9.
Standard 4.16
An electrical installation condition report on the
building’s wiring must be made available.
Timescale: August 2017
Met
10.
Standard 6.3
Staff files containing evidence of pre-employment
checks must be available for the inspector to verify
that all appropriate checks have been carried out.
Timescale: Immediate
Not
met
11.
Standard 6.9
All staff must receive mandatory training in:
Values into practice
Communication awareness
Timescale: Immediate
Not
met
12.
Standard 6.13
All staff must have an annual appraisal of their
performance / PDR.
Timescale: Immediate
Not
met
13.
Standard 2.1
Some woodwork in the communal areas needs
repainting.
Timescale: December 2017
Not
met
14.
Standard 7.2
All shift leaders must hold a QCF level 3
Diploma in Health and Social Care or equivalent.
Timescale: April 2019
On-
going
15.
Standard 2.1
Areas of damp were present in one
resident’s bedroom and must be actioned
The top of a radiator in a shower room was
rusty and should be repaired
An area of flooring by the stairs on the top
floor of the house needs repairing
Timescale: September 2017
Met
Met
Met
16.
Standard 3.16
Support plans must be reviewed
as required, but at least every 6
months
Community Living Assessments
must be reviewed every 6
months
Timescale: Immediate
Met
17.
Standard 3.19
Risk assessments are reviewed when a person’s
needs change, or at least every 6 months
Timescale: Immediate
Met
18.
Standard 7.14
Twice yearly written reports must be produced
following a quality assessment in relation to the
premises, staffing levels and skills, resident
satisfaction and records.
Timescale: December 2017
Met
1.
Recommendations
1. Fire drills should be clearly recorded in the
fire log book.
2. PAT testing by an electrician to take place.
Met
Met
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 2 - Daily Living
People are supported to set and carry out their activities and routines in suitable surroundings. The
environment is conducive to people’s well-being and safety. People live in a home that is safe,
warm clean and comfortable. People have access to the aids, equipment and facilities they need.
2.10, 2.11, 2.12, 2.13, 2.14, 2.15
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 3 – Daily Support
People are confident that the staff will support them to maintain their health and to support their
social and welfare requirements.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 - Environmental and Personal Safety and Comfort
Systems, checks, policies, procedures and staff training ensure that people’s dignity, well-being
and safety is promoted and protected.
4.1, 4.2, 4.3, 4.4, 4.8, 4.9, 4.10, 4.16, 4.17
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 - Staffing
Staff are recruited following a rigorous and robust recruitment programme. There are sufficient
numbers of trained competent staff (including ancillary staff) to meet the needs of the people at
the home. There are robust policies in place to ensure effective supervision and continuous
professional development.
6.3, 6.20, 6.21, 6.22, 6.23
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
People have confidence that the systems in place support the smooth running of the home. The
registered manager is qualified and competent to manage the home. People are consulted about
how the home is run and their opinions are taken into account. The home has an annual
development plan that makes provision for the home to develop and improve.
7.9
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Previous requirements not met
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies with
the principles outlined within the Data Protection Act 2002.
Other areas identified during this inspection /or previous requirements which have
not been met.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies with
the principles outlined within the Data Protection Act 2002.
Other areas identified during this inspection /or previous requirements which have
not been met.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies with
the principles outlined within the Data Protection Act 2002.
Other areas identified during this inspection /or previous requirements which have
not been met.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies with
the principles outlined within the Data Protection Act 2002.
Other areas identified during this inspection /or previous requirements which have
not been met.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies with
the principles outlined within the Data Protection Act 2002.
Other areas identified during this inspection /or previous requirements which have
not been met.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
Outcome
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
6.3 Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies
with the principles outlined within the Data Protection Act 2002.
Other areas identified during this inspection /or previous requirements which have
not been met.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies with
the principles outlined within the Data Protection Act 2002.
Other areas identified during this inspection /or previous requirements which have
not been met.
No
Standard
Requirements/recommendations from
previous inspection
Met/not
met
1.
Standard 1.6
The service summary should be signed by all
relevant parties.
Timescale: 30 June 2018
Met
2.
Standard 4.8
The home’s complaints procedure should be
amended to include the current manager’s
details.
Timescale: Immediate
Met
3.
Standard 4.8
The Autism Initiatives complaints,
compliments and suggestions policy and
procedure should include the contact details
for:
The IOM Registration and Inspection
Unit
Not met
Carried over 28 March 2018
Timescale: Immediate
Not Met
4.
Standard
4.10
Monthly fire extinguisher checks must
be completed
Monthly emergency lighting must be
completed
Not met
Carried over 28 March 2018
Timescale: Immediate
Met
Met
5.
Standard
4.10
Weekly fire alarm tests must take place.
A three hour emergency lighting check
should take place annually.
Timescale: Immediate
Met
Met
6.
Standard
4.10
Staff should receive fire safety training
annually.
Timescale: Immediate
Not met
7.
Standard
4.10
The guidelines for the evacuation of the home
should be amended to reflect the amount of fire
drills the home intends to carry out per year.
Timescale: Immediate
Met
8.
Standard
4.16
An electrical installation certificate should be
produced every five years.
Timescale: 31 May 2018
Met
Requirements/recommendations from
previous inspection
Met/not
met
9.
Standard
4.17
Thermostatic mixer valves should be checked /
serviced to ensure the correct regulation of water
temperatures.
Timescale: 31 May 2018
Met
10.
Standard 6.8
Staff members should receive formal 1:1
supervision with their manager at least four times
a year.
Timescale: Immediate
Met
11.
Standard 6.13
All staff should have an annual appraisal of their
performance.
Timescale: Immediate
Met
12.
Standard 2.1
The following aspects of the environment
must be remedied:
Rear garden fence is broken
Untreated fire doors should be
painted / varnished
Damage on walls to be
repaired
Damage to top of stair
banister to be repaired
Stains on carpets to be
removed
Timescale: 31 May 2018
Met
Met
Met
Met
Not Met
13.
Standard
7.13
An enhanced DBS certificate seen in one
staff file must be removed.
Timescale: Immediate
Met
14.
Standard 3.2
Support plans and
needs assessment
must be reviewed at least every six months.
Not met
Carried over 28 March 2018
Timescale: Immediate
Met
Met
1.
Recommendation
A copy of the NICE healthcare associated
infections – prevention & control in primary and
community care is made available.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 2 - Daily Living
People are supported to set and carry out their activities and routines in suitable surroundings. The
environment is conducive to people’s well-being and safety. People live in a home that is safe,
warm clean and comfortable. People have access to the aids, equipment and facilities they need.
2.10, 2.11, 2.12, 2.13, 2.14, 2.15
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 3 – Daily Support
People are confident that the staff will support them to maintain their health and to support their
social and welfare requirements.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 - Environmental and Personal Safety and Comfort
Systems, checks, policies, procedures and staff training ensure that people’s dignity, well-being
and safety is promoted and protected.
4.1, 4.2, 4.3, 4.4, 4.8, 4.9, 4.10, 4.16, 4.17
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 - Staffing
Staff are recruited following a rigorous and robust recruitment programme. There are sufficient
numbers of trained competent staff (including ancillary staff) to meet the needs of the people at
the home. There are robust policies in place to ensure effective supervision and continuous
professional development.
6.3, 6.20, 6.21, 6.22, 6.23
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
People have confidence that the systems in place support the smooth running of the home. The
registered manager is qualified and competent to manage the home. People are consulted about
how the home is run and their opinions are taken into account. The home has an annual
development plan that makes provision for the home to develop and improve.
7.9
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Other areas identified during this inspection / Or previous requirements which have
not been met.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies with
the principles outlined within the Data Protection Act 2002.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
Outcome
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
6.3 Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies
with the principles outlined within the Data Protection Act 2002.
Other areas identified during this inspection /or previous requirements which have
not been met.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies with
the principles outlined within the Data Protection Act 2002.
Other areas identified during this inspection /or previous requirements which have
not been met.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1- Introduction
Prospective users of the respite service have all the information needed to help make a decision
about using the service.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 2 – Assessment
Each service user must have an up to date assessment of their needs with regard to the service
provided.
Observation
Records
Feedback
Discussion
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 3- Care Plan
A care/support plan must be in place for each service user.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4- Staffing
The service is staffed by individuals who are suitable to work in the service and have the
relevant qualifications and experience to meet the needs of the service users.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 5 – Environment
The registered provider must have written policies and processes that comply with all relevant
guidance and instruction to ensure the safety and suitability of the premises and environment.
5.6, 5.7, 5.8, 5.9 5.12, 5.13, 5.14
Observation
Records
Feedback
Discussion
Other areas identified during this inspection /or previous requirements which have
not been met.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies with
the principles outlined within the Data Protection Act 2002.
Other areas identified during this inspection /or previous requirements which have
not been met.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies with
the principles outlined within the Data Protection Act 2002.
Other areas identified during this inspection /or previous requirements which have
not been met.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies with
the principles outlined within the Data Protection Act 2002.
No
Standard
Requirements/recommendations from
previous inspection
Met/not
met
1
1.6
A written contract to be in place that
includes details of the following:
Terms and conditions of residency;
Details of notice served, support
provided and timeframes;
Details of services/items provided;
Insurance information for personal
belongings;
Timescale: 1 December 2017
Met
2
4.1
The safeguarding policy to be amended to
reflect Isle of Man legislation.
Timescale: Immediate
Met
3
4.10
Fire safety training to be carried out not
more than 3 months following induction.
Timescale: Immediate
Met
4
4.10
Fire alarm testing to be done weekly.
Timescale: Immediate
Met
5
6.1
The Equal Opportunities Policy must be
reviewed and amended to reflect Isle of Man
legislation.
Timescale: Immediate
Met
6
7.3
The policy and procedure file needs to
contain the most recently reviewed policies
and procedures in line with Isle of Man
legislation available for staff.
Timescale: Immediate
Not met
7
7.8
Reports from the responsible person are to
be done three monthly in line with stated
policy.
Timescale: Immediate
Met
Requirements/recommendations from
previous inspection
Met/not
met
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 2 - Daily Living
People are supported to set and carry out their activities and routines in suitable surroundings. The
environment is conducive to people’s well-being and safety. People live in a home that is safe,
warm clean and comfortable. People have access to the aids, equipment and facilities they need.
2.10, 2.11, 2.12, 2.13, 2.14, 2.15
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 3 – Daily Support
People are confident that the staff will support them to maintain their health and to support their
social and welfare requirements.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 - Environmental and Personal Safety and Comfort
Systems, checks, policies, procedures and staff training ensure that people’s dignity, well-being
and safety is promoted and protected.
4.1, 4.2, 4.3, 4.4, 4.8, 4.9, 4.10, 4.16, 4.17
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 - Staffing
Staff are recruited following a rigorous and robust recruitment programme. There are sufficient
numbers of trained competent staff (including ancillary staff) to meet the needs of the people at
the home. There are robust policies in place to ensure effective supervision and continuous
professional development.
6.3, 6.20, 6.21, 6.22, 6.23
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
People have confidence that the systems in place support the smooth running of the home. The
registered manager is qualified and competent to manage the home. People are consulted about
how the home is run and their opinions are taken into account. The home has an annual
development plan that makes provision for the home to develop and improve.
7.9
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies with
the principles outlined within the Data Protection Act 2002.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies with
the principles outlined within the Data Protection Act 2002.
Other areas identified during this inspection /or previous requirements which have
not been met.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 – Staffing
Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies with
the principles outlined within the Data Protection Act 2002.
Other areas identified during this inspection /or previous requirements which have
not been met.
No
Standard
Requirements/recommendations from
previous inspection
Met/not
met
1
4.4
The induction template must be amended to
include safeguarding within the first week.
Timescale: 31 January 2018
Met
2
4.7
Issues relating to the freedom of movement
and personal liberty must be considered in a
multi-disciplinary meeting and decisions
recorded.
Timescale: With immediate effect
Met
3
4.10
The annual fire safety audit checklist
must be reviewed.
The six monthly, fire door
maintenance checklist must be
reviewed.
Timescale: With immediate effect
Met
4
4.11
The health and safety checklist must be
reviewed.
Timescale: 31 January 2018
Met
5
4.12
The infection prevention and control self-
audit and toolkit must be reviewed.
Timescale: With immediate effect
Met
6
4.16
A full and valid electrical installations
condition report must be in place and
available for inspection.
PAT testing and inspection must be
conducted in line with timescales
identified in the service policy.
Timescale: With immediate effect
Carried forward: December 2017
Met
Not met
7
6.2 and 6.3
Staff files must contain details of the
following: Application form, interview notes,
two references, DBS check, health statement
and a contract including terms and
conditions of employment.
Timescale: 31 March 2018
Not met
Requirements/recommendations from
previous inspection
Met/not
met
8
6.5
The induction pack must be amended to
cover all aspects of the care certificate
standards.
Timescale: 31 March 2018
Met
9
6.8
Six supervision sessions per year must be
conducted for all staff members.
Timescale: 31 March 2018
Met
10
6.9
All staff members must access
mandatory training in
communication, health and safety
and nutrition, values in practice.
Staff must update training in food
hygiene, first aid and fire safety.
Timescale: 31 March 2018
Met
11
6.13
An annual appraisal must be completed for
all staff members.
Timescale: 31 March 2018
Met
12
6.16
A minimum of fifty per cent of the staff team
must be qualified to Quality Care Framework
(QCF) level two or three.
Timescale: Ongoing
Not met
13
6.18
All training must be evaluated to determine
impact on staff practice.
Timescale: 31 March 2018
Met
14
6.19
Team meeting minutes must be improved by
clearly identifying actions and carrying them
forward to the next team meeting.
Timescale: With immediate effect
Met
15
7.3
Policies and procedures must be dated on
completion, have a review date identified
and followed up with a timely review.
Timescale: 31 March 2018
Met
16
7.8
More focussed efforts must be made to seek
feedback from relatives on how the service is
run, to feed in to the annual report.
Timescale: 31 March 2018
Carried forward: December 2017
Met
17
7.9
The annual report development plan must be
more clearly linked to outcomes of all quality
assurance exercises.
Timescale: 31 March 2018
Met
18
3.16
All support plans must be reviewed
Timescale: With immediate effect
Met
19
3.19
All risk assessments must be reviewed.
Timescale: With immediate effect
Met
20
3.2
Support plans and risk assessments must
evidence involvement of service users
relatives/representatives where service users
themselves do not have capacity to sign,
confirming their understanding and
agreement with the content.
Met
Timescale: With immediate effect
21
2.1
The hot tap in the kitchen must be mended.
Timescale: July 2017
Carried forward: December 2017
Met
22
7.2
Shift leaders must be registered for or
qualified to QCF level three.
Timescale: 31 October 2017
Carried forward: December 2017
Not met
23
7.6 and 7.7
More focussed efforts must be made to seek
feedback from relatives, professionals and
staff members on how the service is run, to
feed in to the annual report.
Timescale: 31 March 2017
Carried forward: December 2017
Met
Feedback from relevant parties
No feedback has been received.
No feedback has been received.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 2 - Daily Living
People are supported to set and carry out their activities and routines in suitable surroundings. The
environment is conducive to people’s well-being and safety. People live in a home that is safe,
warm clean and comfortable. People have access to the aids, equipment and facilities they need.
2.10, 2.11, 2.12, 2.13, 2.14, 2.15
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 3 – Daily Support
People are confident that the staff will support them to maintain their health and to support their
social and welfare requirements.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 - Environmental and Personal Safety and Comfort
Systems, checks, policies, procedures and staff training ensure that people’s dignity, well-being
and safety is promoted and protected.
4.1, 4.2, 4.3, 4.4, 4.8, 4.9, 4.10, 4.16, 4.17
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6 - Staffing
Staff are recruited following a rigorous and robust recruitment programme. There are sufficient
numbers of trained competent staff (including ancillary staff) to meet the needs of the people at
the home. There are robust policies in place to ensure effective supervision and continuous
professional development.
6.3, 6.20, 6.21, 6.22, 6.23
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
People have confidence that the systems in place support the smooth running of the home. The
registered manager is qualified and competent to manage the home. People are consulted about
how the home is run and their opinions are taken into account. The home has an annual
development plan that makes provision for the home to develop and improve.
7.9
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Other areas identified during this inspection / Or previous requirements which have
not been met.
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 1 – Information, Assessment and Admission
People are confident that the home’s information reflects the services practice and that
written information is accurate and current. The registered provider is able to clearly
establish that the home’s facilities and staff can meet the individual’s specific needs and
requirements. The admission process is planned and people are clear on the terms and
conditions surrounding their residency.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.10 The fire safety and fire safety management in the home meets the requirements
contained within the Health and Safety at Work etc. Act 1974 (UK), the Management of
Health and Safety at Work Regulations 1999 (UK) and the schedule thereafter; in
addition:
The home has a suitable and sufficient fire risk assessment that is compliant with the
above Regulations and the Isle of Man Fire Safety guidance and instructions.
Staff to have appropriate fire safety training on induction and receive further training
not more than 3 months following induction. Thereafter training is renewed
annually. This training to be carried out by a recognised provider.
The means of escape to be adequately maintained and kept free from hazards.
Fire safety systems to be installed throughout the premises and to be installed in
accordance with the relevant British and European Standards.
Testing and maintenance of all fire safety systems to be carried out in accordance
with the relevant British and European Standards.
Records confirm that weekly alarm tests monthly firefighting equipment (including
emergency lighting) checks, and fire drills carried out at least twice per annum are
carried out.
Records of all testing, maintenance and training to be kept on the premises and
these records are to be produced on request of a duly authenticated inspecting
officer.
If the Home has a fire certificate issued under the Fire Precautions Act 1975 (IOM) &
Fire Precautions Amendment Act 1992 (IOM) it will be compliant with the Isle of Man
Fire Safety Department requirements and recommendations. In all other homes any
advice provided by either the Isle of Man Fire Safety Department or the DHSC Fire
Officer will be followed.
Observation
Records
Feedback
Discussion
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.11 The registered person makes available a range of policies and procedures that support
safety, health and hygiene and ensures the home complies with relevant legislation
including the Health and Safety at Work Act 1977 (IOM); Health and Safety at Work Act
1974 (UK) and Management of Health and Safety at Work Regulations 2003.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.12 Staff have received training and follow robust policies in relation to cross infection and
hygiene control and are able to demonstrate their understanding and practice in their
routines. The policies in place are in line with recognised good practice guidelines.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.13 The Food Hygiene Regulations 2007 (UK) are complied with and records made to
demonstrate compliance.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.14 Advice, guidance and records in relation to the Control of Substances Hazardous to
Health Regulations (COSHH) 1999 (UK) are maintained.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.15 Reporting Injuries, Diseases and Dangerous Occurrences Regulations 1985 (IOM)
(RIDDOR) are complied with and recorded.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.16 Electricity at Work Regulations 1989 (UK) is complied with. A certificate of
conformity/safety is available for the home’s electrical installations that are in
compliance with ‘The 17th Edition, Wiring Regulations’ or equivalent. Portable Electrical
Appliance Tests (PAT) are carried out and recorded in compliance with current guidance
and instruction.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.17 Regulation of water temperatures and design solutions to control the risk of exposure
to Legionella micro-organisms (water stored in tanks at 60 °c degrees) and risk from
hot water temperatures (not exceeding 44 degrees °c for baths and 41 degrees °c for
showers and wash hand basins) are carried out in keeping with requirements and
guidance and recorded. (Water Supply (Water Fittings) Regulations 1999 (UK)).
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.18 Central heating and boiler maintenance is carried out and recorded, and where
appropriate compliance with Gas Safety (Installation and Use) Regulations 1994 is
complied with.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 – Environmental and Personal Safety and Comfort
4.19 The service has in place, and displayed, appropriate public liability insurance
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 6.3 – Staffing
Staff files (including volunteers) contain:
A completed application form and interview notes.
All pre-employment checks.
The names and addresses of two referees (not family members) who may be
approached to comment on the applicant’s suitability (one of those referees is the
applicant last employer). Those references are taken up and contained in the file by
the employer.
Evidence of a relevant Disclosure and Barring Scheme check (DBS) and that these
checks have been reviewed by the Employer every 3 years. (Providers will have 3
years to implement this across their service from the introduction of these revised
standards – 2020).
Evidence that a check with the DHSC Social Services has been undertaken (when
introduced).
A statement that the applicant has no known medical condition that will debar them
from carrying out their duties.
Certificates of qualifications and achievements, for all staff.
Registration and revalidation details for Registered Nurses, Social Workers and other
professionals.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.8 Formal quality assurance systems are in place and the registered person uses a range
of tools to measure the quality of the service provided. This will include:
numbers and types of complaints received and any learning resulting from this;
comments and compliments about the service from a range of stakeholders and any
actions taken as a result of stakeholder feedback;
accident and incident reports;
observations of those using the service;
views of staff working at the service;
reports from the responsible person’s visits to the home (or their nominated person)
which must include the notes of the visits.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.9 An annual report lists the success of the service and introduces a written
development/improvement plan based on the outcomes of the quality assessment
exercise. The plan is displayed and available to all. The annual report could include:
achievements in the year;
plans for the future;
outcomes of the quality assessment exercise;
medication audits;
equipment audits;
care plan audits and;
compliments and complaints received and any changes made as a result of concerns
raised.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.10 The registered person has in place recording systems to check and monitor staff
activity to ensure compliance with the terms and conditions of their employment and
the home’s policy and procedural requirements.
Regulation of Care Act 2013 Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 7 – Management Quality and Improvement
7.13 The registered person ensures confidentiality of personal information and complies with
the principles outlined within the Data Protection Act 2002.
Other areas identified during this inspection /or previous requirements which have
not been met.
Full Response Text
Department of Health and Social Care
Rheynn Slaynt as Kiarail y Theay
Regulation of Care Act 2013
Adult Care Homes
17 Kensington Road
Unannounced Inspection
18 April 2018 and
26 April 2018
Registration and Inspection Unit,
Ground Floor, St George’s Court,
Hill Street, Douglas, Isle of Man, IM1 1EF.
1
Contents
Completing and returning your report
To complete your report form, enter text by clicking on the box, use the tab key to move to the
next box.
Provider’s action plan and response
a. Add details of your actions to complete the requirements/recommendations (if
applicable)
b. Confirm you have read and agree/disagree the contents of the report by clicking on the
appropriate box
c. Sign (type name when returning electronically) and date
Return your report to randi@gov.im within 4 weeks
Do not use any other method e.g. links to Cloud or other file sharing services
Part 1:
Service information
Part 2:
Descriptors of performance against Standards
Part 3:
Inspection Information
Part 4 :
Inspection Outcomes and Evidence and Requirements
Part 5:
Provider’s action plan and response
2
Part 1 - Service Information for non-Registered Service
Name of Service: Tel No: (01624) 617409
17 Kensington Road
Address:
17 Kensington Road
Douglas
Isle of Man
IM1 3EP
Email Address: Paul.Quayle@gov.im
Name of Manager:
Paul Quayle – Senior Residential Support Worker (SRSW)
Date of any additional regulatory action in the last inspection year (i.e. improvement
measures or additional monitoring):
None
Date of previous inspection:
21/6/17 & 22/6/17
Number of individuals using or attending the service at the time of the inspection:
Two (2)
Person in charge at the time of the inspection:
Paul Quayle - SRSW
Name of Inspector:
Kevin West
3
Part 2 - Descriptors of Performance against Standards
Inspection reports will describe how a service has performed in each of the standards inspected.
Compliance statements by inspectors will follow the framework as set out below.
Compliant
Arrangements for compliance were demonstrated during the inspection. There are appropriate
systems in place for regular monitoring, review and any necessary revisions to be undertaken. In
most situations this will result in an area of good practice being identified and comment being
made.
Recommendations based on best practice, relevant research or recognised sources may be made
by the inspector. They promote current good practice and when adopted by the registered person
will serve to enhance quality and service delivery.
Substantially compliant
Arrangements for compliance were demonstrated during the inspection yet some criteria were not
yet in place. In most situations this will result in a requirement being made.
Partially compliant
Compliance could not be demonstrated by the date of the inspection. Appropriate systems for
regular monitoring, review and revision were not yet in place. However, the service could
demonstrate acknowledgement of this and a convincing plan for full compliance. In most situations
this will result in requirements being made.
Non-compliant
Compliance could not be demonstrated by the date of the inspection. This will result in a
requirement being made.
Not assessed
Assessment could not be carried out during the inspection due to certain factors not being
available.
4
Part 3 - Inspection information
The purpose of this inspection is to check the service against the service specific minimum
standards – Section 37 of The Regulation of Care Act 2013 and The Regulation of Care (Care
Services) Regulations 2013.
Inspections are generally themed, concentrating on specific areas on a rotational basis and for
most services are unannounced.
The inspector is looking to ensure that the service is well led, effective, safe and compassionate.
No
Standard
Requirements/recommendations from
previous inspection
Met/
not
met
1.
Standard 1.1
An easy read statement of purpose should be
developed.
Timescale: September 2017
Met
2.
Standard 1.6
During the admission process, the person being
admitted and / or their representative are
provided with a written contract that includes
details of:
Terms and conditions of residency;
including fees for services not included in
the contract.
Details of notice served, support provided
and timeframes.
Details of services / items provided (such as
newspapers, hairdressing, chiropody etc.)
and if there is an additional charge.
Insurance information for personal
belongings.
Timescale: October 2017
Met
3.
Standard 4.1
Staff must complete annual refresher training on
safeguarding adults.
Timescale: Immediate
Not
met
4.
Standard 4.5
The home must have a policy and procedure
specific to physical intervention and restraint.
Timescale: November 2017
Met
5.
Standard 4.10
Staff must receive fire safety training annually.
Timescale: Immediate
Met
6.
Standard 4.10
Emergency lighting checks to be carried out
monthly.
Not met
Carried over June 2017
Timescale: Immediate
Met
7.
Standard 4.11
Staff should sign to acknowledge that they
agree with their responsibilities regarding health
and safety in the home.
The health and safety inspection and audit
checklist should have a completed action plan.
Met
Met
5
Timescale: August 2017
8.
Standard 4.12
Staff must receive training on infection control.
Timescale: August 2017
Not
met
9.
Standard 4.16
An electrical installation condition report on the
building’s wiring must be made available.
Timescale: August 2017
Met
10.
Standard 6.3
Staff files containing evidence of pre-employment
checks must be available for the inspector to verify
that all appropriate checks have been carried out.
Timescale: Immediate
Not
met
11.
Standard 6.9
All staff must receive mandatory training in:
Values into practice
Communication awareness
Timescale: Immediate
Not
met
12.
Standard 6.13
All staff must have an annual appraisal of their
performance / PDR.
Timescale: Immediate
Not
met
13.
Standard 2.1
Some woodwork in the communal areas needs
repainting.
Timescale: December 2017
Not
met
14.
Standard 7.2
All shift leaders must hold a QCF level 3
Diploma in Health and Social Care or equivalent.
Timescale: April 2019
On-
going
15.
Standard 2.1
Areas of damp were present in one
resident’s bedroom and must be actioned
The top of a radiator in a shower room was
rusty and should be repaired
An area of flooring by the stairs on the top
floor of the house needs repairing
Timescale: September 2017
Met
Met
Met
Standard 3.16
Support plans must be reviewed
as required, but at least every 6
months
Community Living Assessments
must
be
reviewed
every
6
months
Timescale: Immediate
Met
17.
Standard 3.19
Risk assessments are reviewed when a person’s
needs change, or at least every 6 months
Timescale: Immediate
Met
18.
Standard 7.14
Twice yearly written reports must be produced
following a quality assessment in relation to the
premises, staffing levels and skills, resident
satisfaction and records.
Timescale: December 2017
Met
1.
Recommendations
1. Fire drills should be clearly recorded in the
fire log book.
2. PAT testing by an electrician to take place.
Met
Met
6
Part 4 - Inspection Outcomes, Evidence and Requirements
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 2 - Daily Living
People are supported to set and carry out their activities and routines in suitable surroundings. The
environment is conducive to people’s well-being and safety. People live in a home that is safe,
warm clean and comfortable. People have access to the aids, equipment and facilities they need.
2.10, 2.11, 2.12, 2.13, 2.14, 2.15
Our Decision: Substantially compliant
Reasons for our decision: Resident support plans were examined. Support plans had not been
written on getting up and going to bed routines.
Residents ate their meals at times that suited their preferences.
Support plans on personal hygiene detailed the support required and what the person could do
without assistance. One support plan also stated the person’s gender preferences for when
intimate care was provided.
Residents contributed to the menus and also helped with the weekly grocery shop when it was
their turn.
Residents were able to make their own drinks and snacks.
Residents’ regular social outings and activities had been identified and recorded.
Evidence Source:
Observation
Records
√
Feedback
√
Discussion
√
Requirements
One
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 3 – Daily Support
People are confident that the staff will support them to maintain their health and to support their
social and welfare requirements.
Our Decision: Partially compliant
Reasons for our decision: Comprehensive assessment of needs was completed in a skills, needs
and risks assessment document. These had been recently reviewed.
Nutritional needs were able to be recorded in the dietary needs / eating and drinking section of
the assessment of needs.
7
One resident had a summary of needs and risks completed in their assessment document, but this
had not been completed for the other resident. This should be completed so as to inform the need
for any support plans to be written.
Residents’ known medical conditions should be documented as well as how staff members can
support, maintain and improve the person’s medical conditions. One resident’s main health
conditions had support plans written on them and these had been written in detail. One health
condition, recently diagnosed, had been identified in their assessment of needs, but there was no
support plan written on this. One resident had health conditions identified in their assessment of
needs, but no support plans had been written on them.
Visits to healthcare specialists were recorded. One resident did not have a complete copy of a
health action plan. This document was in place for the other resident, which included a section to
list the dates of when that person last saw a health professional.
A social activities, relationships and well-being section formed part of the needs assessment, as
well as an emotional and mental well-being section. One resident had been identified as being
stressed at times and a support plan should be written on this.
Residents’ faith was identified.
In one resident’s communication section of their assessment of need a specific need had been
identified, but no support plan had been written.
Resident behaviours had been identified in their assessment of needs but no support plans were
required to be written on them.
Resident leisure interests and hobbies had been identified. One resident was very independent of
staff and went out into the community daily. One resident had no set social activities or routines.
Staff offered activities to this resident on a daily basis. The inspector spent time speaking to this
resident on the inspection. He spoke about the things that he liked to do and said that he liked to
go out. Support plans should be written on how staff could encourage him to go out more in the
community.
Contact with friends and relatives should be supported and encouraged. One resident had recently
re-established their relationship with a close relative and a support plan should be written on how
the resident can be supported with maintaining contact.
Personal Emergency Evacuation Plans (PEEP) in relation to evacuating the building in the event of
a fire had been written on both residents.
One resident’s end of life wishes had been recorded and recently reviewed. This information
should be recorded for all residents.
Support plans had been recently reviewed as well as the skills, needs and risk assessment
document for each resident.
Access to advocacy services was available for the residents, if required.
Risk assessments had been written on daily activities that constituted or suggested a risk. These
had been recently reviewed.
8
Both residents had been identified as being in full control of their own finances. One resident kept
some money in a cash tin in the office. Records were kept of the total in the cash tin, with two
staff signatures required to evidence that the money total was accurate.
Residents’ medication was listed and reviewed annually.
One resident had a single page medication self-administration risk assessment on file. This is not
the current version used by the service and had last been reviewed in 2014. Another resident did
not have a risk assessment in place.
One resident was given his medication in a sealed capsule in the morning and evening. He was
then entrusted with taking the medication. A support plan and procedure must be written so that
staff can monitor that the resident is taking his medication.
Medication Administration Record (MAR) sheets were examined and found to have been signed by
staff to indicate that they had administered residents’ medication.
Staff members had received training on medication administration.
Competency to administer medication should be assessed annually for care staff. There was no
evidence that these had been completed by the Senior Residential Support Worker.
First aid training formed part of the home’s training programme. First aid boxes were located both
in the kitchen and in the office.
Evidence Source:
Observation
Records
√
Feedback
Discussion
√
Requirements
Eleven
Regulation of Care Act 2013, Part 2 (37) and Care Services Regulations Part 3 (9)
Standard 4 - Environmental and Personal Safety and Comfort
Systems, checks, policies, procedures and staff training ensure that people’s dignity, well-being
and safety is promoted and protected.
4.1, 4.2, 4.3, 4.4, 4.8, 4.9, 4.10, 4.16, 4.17
Our Decision: Substantially compliant
Reasons for our decision: Risk assessments had been written on the safety of the premises and
environment.
A whistle-blowing policy, as well as the most current Isle of Man Safeguarding policy and
procedures was available. Records had been made and retained on safeguarding issues.
Staff members had received training on
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