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Inspection on 12/08/08 for Salisbury Park (31)

Also see our care home review for Salisbury Park (31) for more information

This is the latest available inspection report for this service, carried out on 12th August 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

CARE HOME ADULTS 18-65 Salisbury Park (31) 31 Salisbury Park Woolton Liverpool Merseyside L16 0JT Lead Inspector Beate Field Unannounced Inspection 12 August 2008 10:30 th Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Salisbury Park (31) Address 31 Salisbury Park Woolton Liverpool Merseyside L16 0JT 0151 722 9729 0151 722 9729 salisburypark@c-i-c.co.uk www.c-i-c.co.uk. Community Integrated Care Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Renata Jayne Davis Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th June 2007 Brief Description of the Service: 31 Salisbury Park is a care home registered with the CSCI to provide care and support to three adults with a learning disability. The home is run by Community Integrated Care. Salisbury Park is situated in a residential area of Woolton in Liverpool and is close to local amenities, bus and rail routes. Salisbury Park is a bungalow. The people who use the service have their own bedrooms and access to two shared shower rooms. There is limited access to one of these shower rooms due to its size. There is a large lounge with a dining area, kitchen, laundry room and a large garden to the rear of the home. The people who use the service have purchased their own vehicle, which gives them the opportunity to access community facilities and go further a field. Parking is available for staff and visitors on the road outside the home. A record of the up to date charges to the people who use the service was not available at the time of this visit. A statement of purpose, which describes the services offered at 31 Salisbury Park, is available for relatives and social and health care professionals to refer to. A service user guide is available. Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection took place over 4 hours and is based on a visit to the home, information received about the service since the last inspection and by an Annual Quality Assurance Assessment (AQAA) completed by the manager. Surveys were sent to staff and health care professionals currently working with the people who use the service, however none were returned to the CSCI. During the site visit to the home time was spent in the office looking at a sample of records and policies and procedures and talking to the manager. A tour of the home was undertaken. The people who use the service and staff were not at the home during the key visit. What the service does well: What has improved since the last inspection? There have been improvements to the records at the home. Care plans now contain clear guidelines as to how staff are to support the people who use the service with behaviours that are challenging and clearer guidelines have been put in place for supporting people with epilepsy. Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 6 At this visit the recruitment records contained all the required information and staff were receiving regular supervision. Further information is now recorded in the communication care plans for the people who use the service. There have been some improvements to the home environment for the people who use the service. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The terms and conditions that the people who use the service have with the home do not fully safeguard their financial interests. EVIDENCE: There have been no new admissions to the service since the last inspection. The people who live at 31 Salisbury Park have lived together for a number of years and prior to living at 31 Salisbury Park, they lived together in another of Community Integrated Care (CIC) homes in Cardwell Road. Should a vacancy arise a new admission would only take place following a full assessment by the service manager and the home’s manager in consultation with the prospective resident/representative and any relevant social and health care professionals. The prospective resident would be able to visit and a gradual move to the home would be planned. The initial assessment procedure indicates that the assessment process covers all of a prospective residents’ needs including their communication, religious and cultural needs. There is a limited amount of information available about the lives of the people who use the service before they came to live at the home. The manager has Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 9 attempted to gather further information but her efforts have been unsuccessful. Each person who uses the service has a copy of the statement of the terms and conditions with the home. These have not been signed. An individual who is independent of the home has not been involved in agreeing that the terms and conditions meet the residents’ best interests. The statement of terms and conditions do not cover all relevant matters such as who pays for holidays and who is responsible for furnishings and soft furnishings in residents’ bedrooms and communal areas. An examination of a residents’ finances at the last visit showed they had paid for a curtain pole and curtains for their bedroom. As the contract is not clear on these matters staff have not got the information they need to ensure that the monies of the people who use the service are appropriately spent. There needs to be a clear record of the care homes charges to the people who use the service. This must indicate what residents are responsible for paying for and what is included in the cost of the fees paid to CIC. It is strongly recommended that an individual independent of the home agree that the contract/statement of terms and conditions meets the interests of the residents in accordance with their wishes and abilities. Since the last visit to the home financial support plans have been put in place for the 3 people who use the service. This indicates the decision making behind using the monies of the people who use the service for a vehicle to enable them to access the community. This approach should be used when any large financial payments are being considered, for example, payment for holidays. An advocate should still be approached as to their opinion as to whether the use of the money of the people who use the service for a vehicle and other items such as payments for holidays is in their best interests. The manager reported difficulties in accessing advocacy services. Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans provide the staff with the information they require to meet the needs of the people who use the service. EVIDENCE: The home operates a key worker system and each person who uses the service has an Essential Lifestyle Plan (ELP), which, provides holistic information regarding their assessed needs, likes/dislikes, and personal goals. In addition, the people who use the service have a care plan, which documents how individual needs are met on a day-to-day basis. Care plans are clearly written in a simple and easy to understand style. Both documents had been reviewed by the home in the last twelve months. Since the last visit the people who use the service have had their placements at the home reviewed by the placing authority. There is now an allocated social worker for each Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 11 person using the service and the manager plans to include the social worker in the next review of the care plans. Observations and records at the home showed that relatives are kept up to date about a residents’ well-being and that they are consulted with when there are important issues affecting a residents’ welfare. Since the last visit to the home the care plans have been revised and now provide more detailed information as to how staff are to respond to any challenging behaviour that may be presented. Records showed that staff have received training around the management of challenging behaviour. Work has taken place to further develop the communication care plans for the people who use the service. The people who use the service are not able to communicate verbally and they do not have Makaton or other communication skills to convey their wishes. However, the staff team have developed an understanding of body language and gestures that are unique to each person and have recorded these in the care plans to help new and existing staff understand what the person might be trying to say. It is recommended that the communication guidelines be further developed with the assistance of a speech and language therapist. It continues to be recommended that the people who use the service have access to a local advocacy group to ensure that they can make independent decisions about their lives with assistance. Risk assessments are in place and are reviewed regularly. They identify any particular hazards and give brief advice to staff on how they should be managed. These include: - environmental, health and handling risk assessments. Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service take part in activities that provide opportunities for their social and personal development. EVIDENCE: Daily records indicate that the people who use the service have access to a variety of activities. The home has television, radio and music facilities and the people who use the service enjoy spending time in the garden when the weather is good, going for walks, going to the cinema and eating out in pubs and restaurants. Other activities recorded included, shopping for food and personal items, visits to local places of interest and music concerts. The staff team support the people who use the service to access the local community. Records show visits take place to local shops, pubs and cafés. On Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 13 the day of the visit the people who use the service had gone out to the cinema and were having lunch out before going to a sensory room. Since the last visit to the service the manager has altered the way staff are deployed to enable the people who use the service to make greater use of activities that are further a field and to increase opportunities for them to pursue their individual interests. This year the people who use the service have enjoyed day trips to the Lake District and The Potteries. The manager has looked at work experience opportunities for the people who use the service, however these were considered not to be beneficial. The people who use the service are involved in household tasks in accordance with their abilities. Family contact is promoted where this is possible. The people who use the service can see visitors in private in their bedrooms. The manager reported that daily routines are flexible in accordance with the needs of the people who use the service. Meal times and bed and rising times suit the needs of the people who use the service. The records of the meals taken by the people who use the service showed that meals are varied and meet their cultural needs. Some records did not reflect the vegetables that accompanied the main meal or the pudding that had been made available. Care is to be taken to fully record this information as it provides evidence that balanced meals are being provided. Fresh fruit was readily available on the day of the visit. The food preferences and dislikes of the people who use the service are recorded in their care plans. Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service receive the personal and healthcare support they require to meet their needs. EVIDENCE: Care plans identify the ways in which personal care tasks should be undertaken for the people who use the service. The care plans include details of the routines of each person and their individual preferences. The people who use the service are provided with personal care by male and female staff. The people who use the service have a Health Action Plan. Records showed that the people who use the service have access to doctors, dentists and opticians when needed. There is also regular access to a chiropodist. Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 15 Since the last visit to the service the guidance for staff on the management of epilepsy has been revised. The guidance now gives clear instructions as to the timescale for administering medication and the dosage. The manager is taking steps to ensure that refresher training around the administration of medication for the management of epilepsy is provided by the end of the year. The guidelines for a person who has not had a seizure for several years had not been revised. Although the staff had received recent training around this, the manager was advised to record the actions to be taken by staff in the event of a seizure occurring. None of the people who use the service would be able to manage their own medicines. Medications are held securely. A check of medicines kept in the home identified that medications are in general being managed appropriately. The administration instructions for some medications had not been entered on to the Medication Administration Record (MAR). The manager reported that the pharmacy will not record administration details for any medications that are not newly prescribed each month. The manager was advised to ensure that a record is made of the administration details and to ensure that these are checked by a second person. The manager was also advised to ensure patient information leaflets are available for all medications available at the home. The training records showed that staff who administer medication had received training in the safe handling of medication in February 2008. Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems in place for managing complaints and adult protection matters ensure that the wellbeing of the people who use the service is safeguarded. EVIDENCE: There is a suitable complaints procedure, which gives the representatives of the people who use the service a clear picture of how to raise a concern or complaint. There have been no complaints since the last inspection either at the home or to the CSCI. There is a corporate adult protection policy in place and the home also has a copy of the Liverpool inter-agency guidelines on adult protection. The staff receive training around recognising signs of abuse and the procedure to follow when reporting an incident of abuse during the induction. Staff have also attended further training around adult protection and the manager is making arrangements for new members of staff to undertake this training. A discussion with the manager indicated that they had appropriately managed an adult protection issue that had arisen since the last visit to the home. The monies of the people who use the service are managed by CIC. Their personal allowances are held at the home and the records of this were checked against the monies available and found to tally. Receipts are kept and staff Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 17 sign records to indicate that money has been received into the home or spent by the person using the service. The manager and service manager carry out regular checks of the finances and an annual audit takes place. As already indicated, the people who use the service would benefit from having an advocate or representative being involved in the care they receive and as part of this should be involved in overseeing how the finances of the people who use the service are managed. Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who use the service would benefit from having access to washing facilities that better support their needs. EVIDENCE: The home is a three-bedroom bungalow situated on a small estate of private properties in the Woolton area of Liverpool. The home is generally well decorated and is furnished in a comfortable domestic style. The people who use the service have single bedrooms. Since the last visit to the home the damaged furnishings have been replaced and the bedrooms have Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 19 been made more personal to the occupants. The manager is continuing to work on making one of the bedrooms more personalised. There are two shower rooms at the home. One of the shower rooms is difficult to access as it is very small and narrow and as a result does not tend to get used. The main shower room used has a walk in shower, which is on one level. The flooring is made of hard quarry tiles. The manager reported that this results in his room becoming very slippy. At the last inspection it was reported that there was an incident where a resident had a seizure and slipped on this floor causing redness to their back. Although there have been no further incidents this flooring may present a possible hazard. Since the last visit to the home an occupational therapist has assessed the shower room and provided a more suitable handrail. On recommendation from the occupational therapist the flooring in the bathroom is being replaced, the manager is pursuing a timescale for this from the housing trust. It is strongly recommended that a full refurbishment of the main shower room take place for the comfort and safety of the people who use the service and to match the good standards of decoration in the rest of the property. The people who use the service should have access to a bath as well as showers to enable them to have a choice of how to wash. There was no office available at the home. Records were stored in the hall, in the kitchen and in the lounge in lockable cabinets. The manager reported that supervision takes place in the lounge when the people who use the service are accessing the garden. This is not acceptable. Steps should be taken to ensure that the manager has a suitable area for carrying out supervision and other managerial tasks. The home was clean and free from malodour on the day of the visit. Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service are safeguarded and supported by the number of staff available and by the training they have received. EVIDENCE: There are usually two members of staff on duty during the day and one waking night staff. A third member of staff is available for some shifts. There are currently 3 staff waiting for their recruitment checks to be completed before they can start work at the home. This will ensure that there are 3 staff on duty on more occasions during the week. 4 of the current staff team of 6 have worked at the home for 4 years or more. This promotes continuity in the care arrangements for the people who use the service. An induction and foundation training programme is provided to all new staff. The training covers health and safety matters, adult protection, equal opportunities, working with adults with a learning disability and promoting the Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 21 rights of the people who use the service. The induction and foundation training programmes have been developed in accordance with the National Training Organisation training targets. Further training provided to staff in the last 12 months has included the management of epilepsy, medication management, risk management and the management of challenging behaviour. Since the last visit to the home the manager has completed an audit of the training needs of staff so that it can easily be identified which staff need training in a particular area. Over 50 of the staff team have an NVQ level 2 in caring for adults with a learning disability. There are plans in place for further staff to complete this training. An examination of a sample of staff records indicated that the required recruitment information was available. An equal opportunities policy is available and it is understood that CIC monitor the effectiveness of this. Policies are available around promoting equality and diversity at the home. The manager reported that training has been made available to staff around this. A sample of staff records were seen and showed that staff are having supervision every two months. The manager has a plan in place for supervision for the next 12 months to ensure that this occurs on a regular basis. Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at the home benefit from living in a well-run service. EVIDENCE: The current manager has been in post since May 2007 and has been registered with the CSCI. The manager has completed an NVQ level 4 in care and management. The manager has undertaken various training courses to keep her knowledge and skills up to date. The manager works directly with the people who use the service and is not allocated separate time to carry out her managerial duties. At present the Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 23 manager reported that she attends to records and carries out supervision during quiet periods of the day. As there are usually only two staff on duty, this could result in some attention not being focused on the people who use the service. The manager reported that when the additional staff have begun working at the home there will be more times when there are 3 staff available which will allow her to dedicate more time to managerial tasks. It is recommended that the manager have allocated time during the week when she is not responsible for supporting the people who use the service and can concentrate on her managerial responsibilities. The service manager visits the home monthly and carries out an audit of the health and welfare of the people who use the service, care plans, accidents, risk assessments both personal and environmental, staffing levels and other issues. The manager has identified an advocacy service to assist with gaining feedback from the people who use the service. However, an advocate has not as yet become available. The views of relatives are gained as to how the service is operating on an informal basis. Surveys are sent to relatives and health and social care professionals each year about how CIC is operating. This does not allow the manager to gather any specific views about 31 Salisbury Park. Surveys that are specifically about the home should be sent to relatives and health and social care professionals. Team meetings take place every 2 months. The home has a set of corporate policies and procedures, which are readily accessible to the staff. Training around safe working practices is made available to staff as part of their induction. There is a rolling programme of training opportunities provided and refresher courses are undertaken when needed. There are policies and procedures and risk assessments available that promote safe working practices. A sample of safety/maintenance check certificates and records were examined and in general found to be in order. A safety check certificate for the gas was not up to date. The manager reported that an up to date check had been carried out. Evidence of this is to be forwarded to CSCI. A record is not made of water test temperature checks. that this information be recorded. It is recommended Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 2 X Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 25 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 17 (2) Requirement The registered persons must ensure that a record of the care home’s charges to the people who use the service, including any extra amounts payable for additional services not covered by those charges, and the amounts paid by or in respect of each person using the service is available at the home. This is to ensure that the financial interests of the people who use the service are appropriately safeguarded. The registered persons must ensure that administration instructions are clearly entered on to the Medication Administration Record (MAR) for all medications. This is to ensure that staff have the guidance they need about medication dosage and frequencies. The registered persons must take action to ensure that the main shower room has appropriate flooring. DS0000025164.V362799.R01.S.doc Timescale for action 12/11/08 2. YA20 13 (2) 12/08/08 3. YA27 13 (4) (a) 12/11/08 Salisbury Park (31) Version 5.2 Page 26 4. YA42 23 The registered persons are to provide an up to date certificate of safety for the gas appliances. This is to demonstrate that the home is being safely maintained for the people who use the service. 12/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA5 Good Practice Recommendations It is strongly recommended that an individual independent of the home agree that the contract/statement of terms and conditions meets the interests of the residents in accordance with their wishes and abilities. It is recommended that the people who use the service have access to an advocate to assist them with making decisions and to ensure that their monies are being appropriately managed. It is recommended that the communication guidelines be further developed with the assistance of a speech and language therapist. The procedure for responding to an epileptic seizure should be clearly recorded for all staff to refer to. Patient information leaflets should be made available for all medications held at the home. Steps should be taken to ensure that the manager has a suitable area for carrying out supervision and other managerial tasks. It is strongly recommended that a full refurbishment of the main shower room take place. The people who use the service should have access to a DS0000025164.V362799.R01.S.doc Version 5.2 Page 27 2. YA7 3. YA7 4. 5. 6. YA20 YA20 YA24 7. 8. YA27 YA27 Salisbury Park (31) bath as well as showers to enable them to have a choice of how to wash. 9. YA39 It is recommended that the manager have allocated time during the week when she is not responsible for supporting residents and can concentrate on her managerial responsibilities. It is recommended that questionnaires be used to find out the views of relatives and other stakeholders about the operation of 31 Salisbury Park. A record is to be made of the checks undertaken of water temperatures. 10. YA39 11. YA42 Salisbury Park (31) DS0000025164.V362799.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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