Inspection on 13/09/07 for 12 Queens Terrace

This inspection was carried out on 13th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

12 Queens Terrace 02/03/07

12 Queens Terrace 22/11/05

12 Queens Terrace 01/03/05

12 Queens Terrace 19/08/04

12 Queens Terrace 11/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 12 Queens Terrace 12 Queens Terrace Fleetwood Lancashire FY7 6BT Lead Inspector Mrs Jennifer Dunkeld Unannounced Inspection 13th September 2007 11:00 12 Queens Terrace DS0000009984.V345636.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 12 Queens Terrace DS0000009984.V345636.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. 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 12 Queens Terrace Address 12 Queens Terrace Fleetwood Lancashire FY7 6BT 01253 876386 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) Ms Maria Elizabeth Gilchrist vacant post Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider must provide an en-suite bathroom in the first floor front bedroom prior to admitting a new service user to this room. The service user currently occupying this room must have exclusive use of one of the two bathrooms. 2nd March 2007 Date of last inspection Brief Description of the Service: This home is situated on the promenade at Fleetwood overlooking the port. It is situated in close proximity to local amenities including shops, public transport and public houses. It is registered to accommodate four adults who have a learning disability. All accommodation is single with one bedroom being provided on the ground floor and the other three on the first floor. There are two bathrooms on the first floor. There are two lounge areas, a dining room and a dining kitchen. The laundry facilities are situated in the basement. At the rear of the property there is a large garden. The range of fees are set by the Local Authority, currently at £627 to £940 depending on the individuals needs. 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home has been inspected against the National Minimum Standards for Adults introduced in April 2002. This inspection was unannounced in that neither the residents or service provider and staff were aware the inspection was to take place on 14/9/07 at 11am. In the report there are references to the “tracking process”, this is a method whereby the inspector focuses on a small group of residents. All records relating to these individuals are examined, along with the rooms they occupy in the home. Residents are invited to discuss their experiences of the home with the inspector; this is not to the exclusion of the other residents who contributed in many ways. This inspection included discussion with the two staff on duty. The service provider who manages the home on a day-to-day basis was off duty. The inspection also included observing the residents and the positive manner in which they were being cared for. The home’s required written information such as the resident’s plans of care were viewed. Each resident has a written plan of care, which is a document outlining the needs of the individual resident and how these are to be met. They cover all aspects of the individual’s life including health, personal care and social activities. Thereby ensuring people are content in the care they receive. The staff spoken with enjoyed their work at Queens Terrace and spoke in a professional manner about the residents. The residents appeared happy in their home and were seen to be well cared for. One man was happily walking around the home and every now and then came to see what I was doing. One carer was out with one of the residents, who had been horse riding but returned while I was still in the home. Another resident was at the day centre. The two staff were busy attending to the needs of the residents, preparing lunch etc. This had an impact on the length of time I felt able to spend in the home without intruding on the usual activities, but did not prevent obtaining the necessary information to write this report and ensure the residents were being well cared for and having their needs met. It is apparent that the home is run around the needs and wishes of the residents, with staff who are keen to ensure the residents are not disappointed by having their plans for the day disrupted. However there are times when the staffing level does not allow for an activity to take place. 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 7 The staff files should be accessible for inspection by the Commission for Social Care Inspection at all times enabling them to ensure appropriate people are being employed with all the necessary checks made. The home is beginning to look a little dusty in places, but the staff are endeavouring to meet peoples diverse needs, cook meals and keep the home clean. It may be that the current staffing levels without someone taking charge on a day-to-day basis is not meeting the needs of the residents. There’s a need to make sure peoples needs are being fully met. The medication cupboard key is now stored in a small cabinet but the cabinet is not locked and is still accessible to others. It was evident that not all staff that administer medication have had training in the safe handling of medication or medication awareness. There’s a need to have this addressed to ensure medication is only given by people competent to do so. The staff supervision sessions should be held every 2 months ensuring they have any training needs identified and are able to discuss any issues with the provider. The daily diaries for the people who live at 12 Queens Terrace generally have recordings of the individual’s meals of the day. The additional recording of activities they have participated in, and how they have interacted would give a better picture of what the day had been like for them. 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. 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 8 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 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 9 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): Standard 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. No-one is admitted to the home without being assessed thereby ensuring the home can meet their needs and wishes. EVIDENCE: There have been no admissions since the last inspection in March 2007. However the senior member of staff stated that people would be assessed prior to admission to ensure the home could meet the needs of the individual. The Pre Inspection Questionnaire completed by the service provider prior to the inspection in March 2007 reflected that there was a pre admission assessment format and this was seen at the time of that inspection. The home Statement of Purpose reflects that all prospective residents would be assessed prior to admission to ensure the home is able to meet the individual’s diverse needs. 12 Queens Terrace DS0000009984.V345636.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): Standards 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 service provider and staff team continue to make sure the needs and personal goals of people are met by having clear care plans for all individuals. EVIDENCE: The case tracking process revealed that there have been no changes regarding the care plan process since the last inspection. They continue to be reviewed regularly with full consultation with the service user. They include details of mobility, communication, health, diet and medication. Risk assessments are in place to make sure people are safe, and these address areas such as chopping food, using taxis and using stairs. 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 11 One man uses a taxi unescorted, there has been a risk assessment that reflects what staff need to do when the man gets in the taxi to reduce the risk of him endangering himself. The management must ensure this risk assessment is robust. Ideally the social worker should be invited to assist in the process of such risk assessments to ensure the persons best interests are safeguarded. The home cares for male and female residents and recognises equality for people choosing to live in a care home. While some of the residents do not have the skills to communicate verbally, the staff have got to know them well and can quickly pick up when someone is not happy. The daily diaries for the people who live at 12 Queens Terrace generally have recordings of the individual’s meals of the day. The additional recording of activities they have participated in, and how they have interacted with each other would give a better picture of what the day had been like for them. One resident was at a day centre that she likes to attend. 12 Queens Terrace DS0000009984.V345636.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): Standards 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 staff generally support people to maintain their place in the community and keep contact with family and friends and have a fulfilling lifestyle, the residents’ benefit from this. EVIDENCE: Staff stated that the good contact is maintained with families and that the service provider has recognised the importance of this. She liaises with families on behalf of those people who cannot communicate themselves There were photos of residents and their families in the home, which added to its homely appearance. 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 13 The residents appeared well nourished and menus reflect a healthy balanced diet. The staff stated that the residents are enabled and encouraged to maintain friendships as this gives them a feeling of well being and are subsequently content in the care they receive. When asked, staff stated that there are occasions when they have been unable to take a resident out, as there were not enough staff on duty. One man needs two staff to take him out. Often each shift has just 2 staff to care for all 4 residents, which means the man cannot go out. Staffing numbers need to ensure that all the people who live at the home are supported to take part in their identified activities. Care plans in general did reflect some of the activities people took part in. Such as horse riding, crazy golf, swimming and Mencap club. At the time of this visit one man was out horse riding. When he returned he was full of smiles having enjoyed himself. The support worker said she had enjoyed being with him as he enjoyed it so much. The senior staff on duty was aware of the needs of the individuals. 12 Queens Terrace DS0000009984.V345636.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): Standards 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans give clear guidance for the best way to support people with their personal care, so staff are assisting in a manner that meets individual needs. People would benefit from having robust risk assessments and having medication securely stored. EVIDENCE: The care plans viewed as part of the case tracking process were seen to be comprehensive in providing clear guidance for staff on how to assist a person that best suits their needs. One of the care plans viewed as part of the tracking process reflected the following: ‘When assisting the person to dress if the person takes an item of clothing off it is because he doesn’t want to wear that particular item. Staff are to 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 15 encourage him to choose another item of clothing’ The staff spoken with were aware of this persons needs and complied with the identified need. Another gave detailed information of how to assist the person to bathe and how often he usually likes to have a bath. Other professionals that have been involved in people’s care include the chiropodist, physiotherapist, communication specialist and the Additional Support Team. Medication is stored in a metal cabinet. During the last inspection in March 2007 medication practices were looked at and found to be in need of reviewing as the key to the medication cabinet was hanging above the cabinet itself and as such medication was not securely stored. Advice was given in relation to this recommending that the senior person on duty keep the key to ensure safe handling of medication. However during this visit the key was stored in a small-unlocked cupboard and as such medication was not securely stored. There is a need to follow the advice offered during the last inspection. Medication records were up to date and accurate. Training should be given to those members of staff who have not yet had training in the safe handling of medications. Each person has a’ meds book’ where all medical appointments are recorded and the outcome of such visits. However these are not always followed up. For instance one entry said, “Went for a blood test should know results in about a week” There was no further entry, so the reader is unaware of whether the results are back or not. Risk assessments were included in the care plans viewed as part of the tracking process. For example one man travels in a taxi unescorted and the risk assessment reflects what staff should do when enabling him into the taxi. Person “may try to get out of taxi; therefore staff are to ensure the taxi door is locked.” Vulnerable people travelling in a taxi unescorted must have a robust risk assessment as part of their care plan, ideally involving the social worker for the individual. One person requires a special diet and this is well catered for. Staff were aware of what he can and cannot eat. During lunchtime on the day of the visit, lunch had been prepared for the residents according to their known likes and preferences. 12 Queens Terrace DS0000009984.V345636.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): Standards 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 people who live at Queens Terrace are protected from abuse by the policies and practices within the home. EVIDENCE: Neither the home nor the Commission for Social care Inspection have received any complaints since the last inspection in March 2007.The homes complaints record book was not available during this visit, as the staff did not know where it was kept. The manager has made sure that all service users and/or their relatives have had a copy of the complaints procedure, which is in the Statement of Purpose. The four people accommodated would probably not be able to make a formal complaint, but staff are aware of behaviour changes and gestures that may indicate a person is not happy with something. There are opportunities on a daily basis for service users to make their wishes and opinions known. Staff are given guidance around “Awareness of abuse” through National Vocational Qualification (NVQ) in care and through Learning Disability Award Framework (LDAF). This will go some way to ensure residents are protected from abuse. 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 17 The manager ensures POVA first is completed for all staff prior to commencing work. The member of staff spoken with said she had filled in a Criminal Record Bureau (CRB) clearance form prior to commencing work and received clearance. The senior staff member on duty felt he could only let me see his file, as the others are confidential. This did not contain an application form. The addition of a staff application form would ensure people’s full employment history is known and any gaps in the employment record can be investigated. Since the last visit in March 2007 the practice of ensuring 2 witness signatures for all financial transactions on behalf of the residents has been adopted, to safeguard the resident’s finances and protect the staff from wrongful accusations. Staff spoken with were aware of what to do should they suspect abuse has occurred “inform Maria” service provider. 12 Queens Terrace DS0000009984.V345636.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): Standards 24, 25 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents’ benefit from living in a homely, comfortable and safe home. EVIDENCE: A tour of the home revealled that the home is well maintained and the residents individual bedrooms are full of their own possessions which reflect the individuals personality. They are decorated to the liking of the individual resident and as such are very different in appearance. 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 19 None of the bedrooms have en-suite facilities, however there are two bathrooms situated on the first floor. There are two large lounges in the home, one of which is used for the use of the computer, while the second one is where service-users and staff watch the television. The home has a dining room and a kitchen/diner. The residents were seen to be free to wander around their home. All the rooms were bright and had a homely feel. The home was not quite as clean as it had been during the last visit. For instance there was dust on the windowsills and pictures on the stairway. The toilet seat in one bathroom was broken off the toilet. When asked how this would get repaired or replaced the staff explained how one of them would see if it would repair and if not buy a new one and fit it. The staff work very hard in an endeavour to ensure the residents needs are met, their groceries are purchased and their meals made as well as trying to keep the home clean and in a decent standard of repair. 12 Queens Terrace DS0000009984.V345636.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): Standards 32, 34, 35 and 36 Quality in this outcome area is adequate The residents would benefit from having a staffing level that fully meets their needs. EVIDENCE: Throughout each day there are 2 staff caring for 4 people with complex needs. On occasional days there are 3 staff to enable one man who needs 2 staff to support him on activities out of the home. When asked, staff explained that sometimes he sometimes has to miss going out, as there are only 2 staff on duty. After 4pm each day there is only one member of staff on duty which means people can not go out, unless they travel to their destination, for example to the local Mencap club, in a taxi unescorted. The support staff are also responsible for the cleaning of the home. There is a need to ensure the staffing levels meet the needs of the residents. As previously stated vulnerable people travelling in a taxi unescorted must have a robust risk assessment as part of their care plan, ideally involving the social worker for the individual. 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 21 The senior person on duty allowed his staff file to be viewed, this contained all the relevant information except an application form. However he had commenced employment prior to the last inspection in March 2007 when the home was offered advice in relation to the need for an application form for all people applying for employment in a care service. A recently employed member staff said she thought she had completed an application form while at the providers home. Other staff files could not be viewed, as the staff on duty did not feel able to access the files as they contain confidential information. There is a requirement that staff files are available for inspection by the Commission for Social Care Inspection at any time day or night. The senior support worker on duty stated that all staff have the necessary checks made about them. This includes police checks known as Criminal Record Bureau clearance, prior to commencing employment. These practices ensure that only people who are fit to do so support the people receiving services. The one staff file viewed reflected that supervision is not taking place on a regular basis. Formal supervision is an opportunity for management to discuss any training needs with the individual and give them an opportunity to raise any areas of concern or suggestions to improve the quality of the service. There are 5 support workers currently employed of which 2 have achieved a National Vocational Qualification in care at level 2. Another member of staff has almost completed this. 3 staff have completed a ‘Medication Awareness’ course. Other staff who have not received training in respect of medication should not be responsible for the administration of medication. A training plan should be developed to ensure all staff attended relevant courses such as Health and Safety, Fire prevention, Food Hygiene etc. 12 Queens Terrace DS0000009984.V345636.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): Standards 37, 38, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents would benefit from living in a home that is effectively managed on a day-to-day basis. EVIDENCE: The people who live at 12 Queens Terrace lack the capacity to mange their own finances and the staff assist them to budget. There is a well maintained record of all financial transactions. Advice was given that people should be encouraged to bank the money not required for the months expenditure, rather having large sums in the home. 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 23 The residents could arrange to have a standing order payable to the provider for their assessed contributions to the fees. This would reduce the necessity for trips to the bank unless people want some funds for their daily expenditure. The service provider has of necessity had to have time off from working in the care home, but as time goes on it is apparent that the home is lacking the input of day-to-day management. This coupled with the current staffing level is having an adverse effect upon the daily lives of the people living in the home. For example, the lack of robust risks assessments, staff endeavouring to perform all tasks about the home, activities for people not always taking place and not as frequent. There is evidence that the safety checks such as checking fire alarms in the home are carried out to ensure people are protected. 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 x 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 2 2 X X 2 X 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement The key to the medication cabinet must not be left unattended. This has not been implemented as advised during the last inspection. A new timescale for action has been set. The service provider must ensure there are robust risk assessments to ensure the health and welfare of the residents are protected. The service provider must ensure that the staffing level meets the needs of the residents The service provider must ensure the staff are appropriately trained to carry out their role. The service provider must ensure all staff receive regular supervision. The service provider must ensure the home is maintained to a good standard of cleanliness The service provider must ensure that staff files are available for inspection by the Commission for Social Care DS0000009984.V345636.R01.S.doc Timescale for action 30/09/07 2 YA9 12(1)(a) 16/10/07 3 4 YA12 YA33 YA33 18(1)(a) 18(1)© 31/10/07 15/01/08 5 6 7 YA36 YA30 YA34 18(2) 23(2)(d) 19 Schedule 2 16/10/07 31/10/07 30/09/07 12 Queens Terrace Version 5.2 Page 26 Inspection at all times 8 YA31 18(1) The registered provider must manage the care home on a daily basis or appoint a manager to do so. 30/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA32 Good Practice Recommendations New staff should complete LDAF, and 50 of staff should achieve NVQ level II in care. A training plan should be developed to make sure staff train in infection control, moving and handling, medication and health and safety. The registered provider should achieve the Registered Managers Award. A staff application form should be developed for future applicants The daily diaries of people need to reflect the daily activities and interactions of the day. 2. YA35 3. YA37 4 5 YA34 YA10 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 12 Queens Terrace DS0000009984.V345636.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!