Inspection on 19/06/07 for 145-147 Masons Road

This inspection was carried out on 19th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

145-147 Masons Road 04/07/06

145-147 Masons Road 08/12/05

145-147 Masons Road 16/08/05

145-147 Masons Road 07/03/05

145-147 Masons Road 29/06/04

145-147 Masons Road 17/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 145-7 Masons Road 145-147 Masons Road Stratford On Avon Warwickshire CV37 9NX Lead Inspector Martin Brown Key Unannounced Inspection 19th June 2007 10:00 145-7 Masons Road DS0000057999.V337920.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 145-7 Masons Road DS0000057999.V337920.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. 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 145-7 Masons Road Address 145-147 Masons Road Stratford On Avon Warwickshire CV37 9NX 01789 414551 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) www.turning-point.co.uk Turning Point vacant post Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2006 Brief Description of the Service: 145-147 Masons Road is a care home for four adults with learning disabilities. The Primary Care Trust owns the home and the service providers are Turning Point. The home comprises two maisonettes, one ground floor and one first floor. There is a small office and laundry on the ground floor separate to the maisonettes. The home was opened in 1994. Up to two service users are accommodated in each of the maisonettes. The home is a domestic property close to a supermarket and is close to the town of Stratford on Avon. All of the bedrooms are singles without en-suite. Each maisonette has two bedrooms, a lounge, kitchen and bathroom. There is a shared laundry, garage and garden. The upstairs flat is only suitable for service users who are independently mobile. The acting manager informed me that current fees per person remain as last year, £1,312 per week. Additional charges are made in the form of contributions towards the running of the home’s vehicle. The home now has two service users, one in each flat, in preparation for plans to operate as a domiciliary care service. 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over four hours during a weekday. During that time, both residents were spoken with, as was the acting manager, and the two staff on duty. Policies and procedures and care records were examined, and the two residents were ‘case tracked’, that is, their experience of the service provided by the home was looked at in detail. The recently introduced Annual Quality Assurance assessment was fully filled in and returned by the management to further inform the inspection, as was accumulated evidence from regulation 37 notices, and information from regulation 26 visits regularly provided by the service. One relative was contacted by telephone and gave views on the service. The inspector was made welcome throughout the visit. What the service does well: What has improved since the last inspection? There have been major improvements to the environment, most notably, the replacement of an old and ineffective heating system with one that works and can be properly controlled. Staff have ‘spruced up’ various rooms, following the departure of one service user, making most areas much more pleasant. Communal and personal areas were much tidier than previously. The departure of one service user has given the remaining service user in that flat much more freedom. All staff commented on how much more relaxed and happier he was, to have this room to himself. Staff also commented that the reduction enabled them to spend more time meeting individual needs on a one-to-one basis, and that this was making the two service users far happier, as they were now far less restricted in what they could do by staff being available. 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 145-7 Masons Road DS0000057999.V337920.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 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs and aspirations of any prospective user of the service would be assessed according to existing policies and procedures. EVIDENCE: These standards were not fully inspected on this occasion, on the understanding that this service does not anticipate any further service users in the foreseeable future, as it plans to apply to de-register as a care home, and become part of a domiciliary care service. Both current service users have been there a number of years. The Annual Quality Assurance Assessment returned by the service detailed the admission procedure that would be implemented should there be a need to for this. 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual plans reflect individual needs, and support and reflect service consistency in meeting these needs. Service users are able to make decisions, within the framework of acceptable risks and working towards greater independence. EVIDENCE: Each service user has a comprehensive folder, detailing needs and how they are met. Daily records are kept, and these are transferred to a monthly summary, which outlines and illustrates achievements for that period. There is also a service user-friendly guide, well illustrated by photographs, for each person. These are kept in the office, rather than in service user’s rooms, as they had been frequently damaged when this has been attempted. A discussion was had with the manager about re-introducing them into individual living areas, in laminated formats, to better protect them against rough handling. Service users are able to look at them when they wish, and have done on previous occasions, although on this occasion they were more interested in other aspects of their day, such as going out, talking to staff, or 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 10 showing me new items of clothing. Life storybooks were seen to convey positive images, with lots of photographs, of service users’ achievements. The manager was able to demonstrate progress in one person’s social skills in that he was successfully being encouraged to be tidier. This was confirmed by seeing his flat, and the service user proudly showing me his new slippers and other smart clothes. One service user had previously expressed a long-held wish to move to a more independent setting. This wish has now been met, with this person having recently moved to his own flat with support from another service provider. Staff all commented on the beneficial effect that this has had on the remaining resident in that flat who is now enjoying having the flat to himself, even though he had not previously given any indication that sharing the flat was a problem. Residents continue to be encouraged to make decisions about their lives; and to have these respected, even when this causes practical difficulties, as when service users have difficulties in maintaining a consistent pattern of decisions, as, for example, in attending a collage course regularly. Discussions with staff and management show that residents’ choices are balanced with their need to be supported in the development of social skills, in areas such as personal hygiene, and unsocial behaviour. Individual risks are assessed and managed, often within guidance concerning overall living arrangements, choice, and independence. A discussion was had with the manager over a number of risk assessments that appeared to be more ‘system focussed’ rather than based on individual needs. The manager agreed that many of these could be usefully incorporated within individual service user guidelines, possibly in a more ‘user friendly’ way. 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy a great deal of supported freedom in what they do, and are encouraged and supported in benefiting from a broadly healthy lifestyle and diet that does not conflict with their wishes. EVIDENCE: One service user had just returned from a holiday, supported by staff, with a friend who used to live at Mason’s Road, and with whom he maintains regular contact. He had little to say about the holiday, other than where it was and that he enjoyed it, being more keen to focus on more immediate matters, such as going out that morning. The manager advised that the reduction to two residents enabled one–to-one staffing to take place, which allowed for individual needs to be catered for with both service users being better able to be supported by staff in undertaking activities that they wished to do. The staff member who accompanied one resident out into town was able to describe the activities, showing that they allowed the service user to do as he wished, with the staff being there as support as necessary. The outing, which the staff 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 12 described as fairly typical, involved the service user having a walk to feed the ducks, going into a few shops, buying a small item, meeting a Navy recruitment roadshow, and returning when he was ready to. The service user was full of smiles on his return, as he was all day. The other service user chose not to go out, although this option was open to him later. Other activities include the weekly local Gateway club and a monthly disco at a nightclub, enjoyed by one service user. One service user has regular family contact, another has a particular friend he enjoys visiting, and who also visits him. A relative spoken was happy with the way contact was managed, by regular visits. Meals are flexible, with staff supporting service users in shopping for, preparing meals and encouraging healthy balanced meals and a variety of experiences, including eating out. Service users make themselves snacks and drinks, and are supported in this as necessary. This was in evidence during the inspection. Kitchen areas continue to be well maintained and tidy. 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in a way that supports their needs, and have their physical, emotional and health needs met. Clearer, more accessible guidance on the administration of specific ‘as required’ medications will better support safe and appropriate administration of such medications. EVIDENCE: Residents continue to be supported in regular health appointments, and health professionals, including speech and language therapists, are involved as necessary. The manager was able to point to the purchase of an electric toothbrush as being of great help in encouraging a service user in better dental hygiene. One service user has a walking aid for walking any distances outside the home, and had recently had specific health needs reviewed with a relevant specialist, with further appointments made as necessary. The manager advised that there were plans for one service user to get some drums as he had demonstrated an aptitude and liking for these, and it was thought they could help him relieve stress at times. The manager hastened to 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 14 add that neighbours, and the other service user had been made aware of this and were broadly supportive, and that it would occur at reasonable times. One service user suffers from epilepsy, and the epilepsy nurse is involved in a review of medication and general treatment in respect of this. Behaviour systems, supported by outside professionals, are in place as needed, and speech and language therapists also provide input as needed. In one example given, they have led a co-ordinated approach to helping one service user’s eating be more leisurely and effective. Medication administration and recording was looked at. Medication recording was accurate; there were no unexplained omissions, and amounts recorded tallied with amounts of medication remaining. Medication records included photographs of each service user, and a brief guide to how they prefer medication to be administered. The manager advised that current service users have no known allergies. This fact was not recorded. There were two ‘as required’ medications noted, but there was it was not clear in the medication folder as to why and when these may be required. The manager advised that this would be rectified. For one of the medications, this guidance was currently being reviewed, and the proposed new guidance was seen. 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can feel that their views are listened to and acted upon and that they are protected from abuse, neglect and self–harm. Their financial well–being is potentially compromised by the current financial arrangements regarding transport. They can feel confident that the manager is working to resolve this to their benefit. EVIDENCE: One complaint, made by a service user, had been logged over the past year. The actions following this sensitive complaint were discussed with the manager, who was able to give a detailed explanation of the investigation and its consequences, including relevant referrals under the Protection of Vulnerable Adults. It is noted that one service user has now left the service, in compliance with a long-standing wish to live more independently. Observations of the interactions between service users and staff demonstrated that their views were listened to and acted upon; this was confirmed by individual files and records, and discussions with staff and service users. The service has policies and training in place regarding physical intervention; staff showed a good knowledge of these, and a good appreciation of service users’ wishes and needs. Service users are expected by the organisation to pay a set amount towards transport costs for a vehicle provided for them. The manager felt that this was an unrealistically high amount, for a vehicle that was a much higher 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 16 specification than was needed – a seven-seater vehicle, for use by two service users who invariably travel as single individuals. He felt this was not a wise way to meet individual transport needs, had been arranged at the time without properly consulting service users or their representatives, and advised that he was seeking a change to it. 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a much improved environment, now properly heated. The overall homely nature of the home is still compromised by the poor or unfinished state of the bathrooms. EVIDENCE: The environment has much improved, thanks to individual efforts from the staff and manager, and support from the organisation in funding the replacement of an inadequate heating system with one that provides heat when needed. Individual service users were happy to show me around, and showed a pride in their surroundings, rather than, as previously, a number of concerns about shortcomings in the home. One service user has recently left. Staff have worked busily and effectively to convert a bedroom into an attractive lounge, much appreciated by the remaining service user there. His bedroom has also been redecorated and improved, as have communal areas. 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 18 The upstairs lounge was also smart and tidy. Both kitchens continue to be wellmaintained. Both bathrooms still require attention. The upstairs bathroom, in particular, still has walls that are in need of stripping and repainting. This was commented on by a relative, as an area that still required attention, although it was much appreciated that there had been much improvement made, notably with the heating, to an environment that was previously poor in many aspects. Both flats had posters on the wall, proclaiming the virtues of the organisation. These did not appear to serve any useful purpose for the service users. the manager advised that one service user liked posters on his wall, whilst the other did not. Both appeared indifferent to the posters. The laundry room was functioning properly, now being properly vented and steam-free. 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are benefiting from a staff team who are familiar with their needs and how to meet them, and who are able to provide individual support. EVIDENCE: The manager enthused about the quality of staff he now has, and the fact that there is now a one-to-one ratio with service users, enabling them to properly meet service users’ day-to-day wishes. This was apparent in observations during the inspection, as staff were able to dedicate themselves to supporting one service user, whether this be enabling them to go out when they wished, or to be on hand to guide them appropriately in, for example, making cups of tea. One staff commented positively on the current staff team, saying that ‘everyone worked together well’. Recruitment files were not seen on this occasion as the manager advised that, not expecting an inspection or any other reason to need those secure files, he did not have the necessary key with him. Information provided on the Annual Quality Assurance Assessment demonstrated a robust approach to recruitment 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 20 and the necessary checks and procedures remains a priority. Other services within this organisation inspected more recently have shown a robust approach to appropriate recruitment, with all necessary checks in place. There continues to be a need to use agency staff at times. One of the staff on duty was from an agency. He was able to demonstrate a good awareness of the needs of the person he was working with, and spoke knowledgeably of the induction he had had, and where and from whom he had obtained necessary information. He said that this was the fifth time he had worked at this service. The organisation has a robust policy, recently issued to local services, on the use of agency staff, outlining expectations and limitations. The permanent staff on duty were able to demonstrate, in discussion and by example, a good awareness of the needs of the service users, and a commitment to meeting those needs and valuing people as individuals. Staff and the acting manager spoke of the availability and provision of training on all mandatory topics as well as those specifically linked to the needs of the service users. Staff training records, confirmed by discussion with the acting manager, showed that at present, less than 50 of staff have achieved National Vocational Qualification level two. The acting manager advised that this was in the context of a small staff team with a high turnover until recently, with a number of staff in post for less than six months, and that he would expect further numbers of staff to put in for and achieve this qualification over the coming year. 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a home that is being well-run, where their health, safety and welfare is promoted, and where their views and considerations for their well-being underpin development at the home. The certainty of having a registered manager, and of knowing how the service is going to be run in the future, may help current service users to feel more secure, although their own concerns tend to be based more on day-to-day practicalities, such as what they are going to do that day. EVIDENCE: The home is currently being run by an acting manager who has not been registered, and does not have the Registered manager’s award. He advised that he is to register to do this, as well as to do National Vocational Qualification level 4. There is current uncertainty regarding his role, as the service proposes to apply to run as part of a domiciliary care service. The 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 22 improvements to the service during the time the home has been run by the current acting manager is noted. Much needed improvements to the environment have taken place, the much-anticipated move of a service user has finally taken place, and the current two service users appear more settled. Service users have Person Centred plans, regular reviews, and it was apparent from observation and discussion with staff and service users that the service heeds their views both in day-to-day work and in long-term planning. The main concern expressed by the acting manager was to maintain the safety and well-being of the service users, and to maintain an individualised service for them, no matter how it was managed. One service user has regular family contact. His closest relative was contacted and was positive in her views of the service, saying that she was kept informed of any significant events, was regularly invited to reviews and her views sought on all matters raised concerning the service user. Records were seen of these ‘family forums’, held three monthly, at which those with a significant interest in the service user’s well-being were invited to reviews. One service user does not have any family contact, and the desirability of him having an advocate or befriender was discussed with the manager. As there are now only two service users, both with their own flats, consultation is done on an individual basis. Staff are very much aware that service users tend to be spontaneous in their wishes, and previously agreed plans are frequently jettisoned. The home receives regular visits from the service manager, as required under regulation 26 of the Care Standards Act. These are detailed, and are a regular audit of how the service is developing, with shortfalls being identified along with actions required to remedy them. The acting manager advised that all required health and safety checks continue to be carried out. Water temperature checks and fridge/freezer temperatures were seen to be carried out regularly; during the inspection electricians arrived to conduct testing of all sockets, replacing those that did not meet the required standards. 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 23 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 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 x 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 3 2 x 2 x 3 x x 3 x 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 24 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 There must be clear, accessible written guidance concerning the administration of ‘as required’ medication, so that service users can be confident that staff are dispensing it when appropriate. The upstairs bathroom must be renovated, so that the service user has a pleasant environment in which to bathe and shower. (This is an outstanding requirement from the previous inspection). The service must detail its proposals to have a suitably qualified and registered manager to run this registered service.(This is an outstanding requirement from the previous inspection) Timescale for action 30/07/07 2. YA27 23(2) 30/09/07 3. YA37 8,9 30/09/07 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 25 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 YA20 Good Practice Recommendations To help ensure any inappropriate medication is not administered, it should be clearly recorded in the medication folder whether or not any service user has any known allergy. It is recommended that notices directed at staff be kept in relevant folders, rather than displayed on walls other than the office. A greater percentage of staff achieving National Vocational Qualification level 2 would better evidence the service’s achievement and application of appropriate training for it’s staff. It is recommended that an advocate or befriender is sought for one service user who has no family contact. 2. YA24 2. YA35 3. YA39 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands Regional Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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 145-7 Masons Road DS0000057999.V337920.R01.S.doc Version 5.2 Page 27 - 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. 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