Inspection on 06/11/07 for 178 London Road

This inspection was carried out on 6th November 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

178 London Road 21/11/08

178 London Road 08/02/07

Similar services:

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Hillview Farm

Dalewood Respite Care

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

CARE HOME ADULTS 18-65 178 London Road 178 London Road Waterlooville Hampshire PO7 5SP Lead Inspector Ms Sue Kinch Key Unannounced Inspection 6 November 2007 09:00 th 178 London Road DS0000067252.V347396.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 178 London Road DS0000067252.V347396.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. 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 178 London Road Address 178 London Road Waterlooville Hampshire PO7 5SP 02392 231983 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) H46013@mencap.org.uk Royal Mencap Society Mrs Heather Edney Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2007 Brief Description of the Service: 178 London Road is a converted detached property, which has been refurbished to provide an environment for 3 specific service users. This includes 1 resident having a self-contained unit with a lounge, bedroom, kitchen and bathroom. Another resident has his own lounge and en suite bathroom with a shower adjacent to his bedroom. The third resident has his own bedroom with an en suite bathroom. The home has its own vehicle to transport residents. Staff are provided for 24 hours per day. The exact fees for the home were not known at the time of the inspection but are at least £1900.00 per week. 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s second inspection since registration on 22nd August 2006. The inspection consisted of a review of the file held at the CSCI office and of an Annual Quality Assurance Assessment (AQAA) document completed and sent to CSCI by the manager before the inspection visit. The visit took 6.5 hours. The residents rely mainly on non-verbal communication and elements of their preferences and choices could only be attained through observation and staff and relatives’ views. All residents were met. Five staff and the manager were spoken with during the visit. The physical environment was assessed and some records and documentation were examined. Surveys were sent to a sample of health and care professionals involved in the home. None were returned. Three completed survey forms were returned from staff. Relatives also provided written and verbal feedback about the service. What the service does well: What has improved since the last inspection? What they could do better: The staff level has been reviewed but is not comprehensive enough to cover all of the issues for residents over a 24 - hour period. Although the manager has assessed staffing levels as 1-1, at times this is not always provided leaving a risk of needs not being met in relation to choice, challenging behaviour, mental 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 6 stimulation and activities. Although the manager says that there has been decrease in reports of incidents staff levels must not be reduced below the assessed need. Residents must have more opportunities for a fulfilling lifestyle based on their assessed needs. Confirmation must be obtained from the local community or district nursing team that training for staff in administering bodily invasive medication meets their expectations. Any further instruction given must include an assessment of staff competence to meet residents’ needs. Staff recruitment records must be held in the home and this includes relief staff and temporary staff. 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. 178 London Road DS0000067252.V347396.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 178 London Road DS0000067252.V347396.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. Residents benefit from a service that has been has been tailor made to meet their assessed needs, although residents would benefit from the management ensuring that the level of staffing assessed as needed is provided. EVIDENCE: It was found at the last inspection visit that the residents had moved to the home from another Mencap home. The transition was carefully planned and involved discussions with involved professionals, such as social services’ staff. Each person’s records included assessments of need. The physical environment was designed and refurbished to meet the individual needs of each person and to take account of their individual wishes. There have been no further admissions to the home since and so records were not viewed on this occasion. Since the last inspection staff levels have been reviewed but there are still periods when the residents are not provided with the 1-1 staffing that they are assessed to need. This is referred to in details in the staffing section. 178 London Road DS0000067252.V347396.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents would have greater choice and their needs met more often if the staff level and deployment was sufficient to meet those needs. EVIDENCE: There are two files for each resident, which contain care, plans and person centred plans. Files for two residents were viewed at this inspection. They include details of the routines of residents, their preferences and wishes, and the support needed from staff. A large range of issues are assessed including communication, health, personal care, activities, emotional needs and challenges. There are a number of risk assessments for each person with action identified for staff to follow to minimise these. There was evidence of care plans and risk assessment being updated since the last inspection although the monthly reviews with key workers are not consistently held. The manager said that work is to take place to improve the care plans to give staff further guidance for meeting residents’ needs. 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 10 Family members consulted said that staff were supportive and work individually with people. Staff spoken with have a good working knowledge of the needs of each resident. One example of this was a description by a member of staff of the way that one resident communicates needs and how signs of stress or challenging behaviour is picked up. This was reflected in the care plan. Another staff member explained some of the risks to residents and how staff are usually deployed to assist with this. Positive support plans are also in place for guiding staff when working with more challenging behaviours and examples of these being implemented were noted such as talking gently and making suggestions for alternative activity. Staff comments were received though about the homes ability to meet needs in relation to risk when staffing levels are reduced. The main areas of unmet needs noted from information obtained before and during the visit are social stimulation and activities. For one person it was noted that although the activity plan included an activity external to the home on most days, in a period of nineteen days in October and November, the daily records recorded five trips with little information about what support was given to achieve this, why it hadn’t happened and alternatives offered. A staff member said that the resident can get bored and the goals related to shopping are not worked on. A staff member also commented that the number of activities had reduced for a second person and it was noted that as a staff member from each shift was now supporting another registered home over the tea period this person was not able to have 1-1 one support with cooking at tea-time. Staff levels are addressed in the staffing section. 178 London Road DS0000067252.V347396.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 adequate. This judgement has been made using available evidence including a visit to this service. Although social and recreational needs are assessed residents would benefit from more opportunities to pursue their interests and activities outside the home. EVIDENCE: The care plans include activity plans and the running records sampled indicated that some in house activities take place. However, there was not enough evidence that external activities are taking place as frequently as suggested in the plans. Therefore some of the residents’ choices are not supported regularly. One resident likes to go for drives, walks, seeing animals and shopping but there was little evidence of this. Another person had recently lost an outreach service from a day service and although in a recent key worker reviewed it stated that goals were being met, a staff member said that the resident was going out less and was not able to cook daily due to the staff ratio being decreased. 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 12 In the evenings the staff ratio is not enough to provide activities outside the home unless planned in advance. Two of the residents need a ratio of 2-1 in the community and this would leave the third member of staff to work with two people needing a 1-1 ratio each. At times there are only two staff during parts of the evenings so if all three residents needed support at once in their separate areas of the home this would not be possible. The home has a car for taking people out. The manager said that most staff are drivers and most have been trained in SCIP but on the morning of the inspection there were not enough staff to support an external activity although a resident was asking to go out. When the afternoon shift started the external activity took place but was time limited, an issue raised at the last inspection. Relationships with families are supported and those spoken with said that they had regular contact with the staff and felt able to raise issues if necessary. They spoke of the staff and management support in maintaining contact and being informed. There is a new menu for people living at the home and the food provided is recorded in the running records. Preferences about food are recorded. There is evidence of snacks being offered and pancakes were made during the morning of the inspection, for one resident who particularly enjoyed them. Another resident has recently been supported to visit a dietician. 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are met. EVIDENCE: Personal plans are in place with details of how personal care needs are to be met including the preferences of the people living at the home. One family member asked said that they thought that their relative had good support with personal care and that personal laundry was cleaned regularly. The records for people in the home also include health needs and there are monitoring sheets to record the support obtained from health professionals. Two relatives asked said that health needs were given attention by the home and that support was given to attend external appointments. Verbal and written evidence was received of appointments with from a chiropodists, doctors, psychiatrist, dentist, dietician and speech and language therapist. One relative also spoke of a medication review. Medication is stored securely in the home and records sampled were fully completed. Where stocks were checked against the numbers of tablets 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 14 administered accuracy had been maintained. A member of staff has a specific role to monitor the handling of medication. In the last inspection report a requirement was made about staff having clear procedures for staff to follow when administering specific ‘body invasive’ medication ‘as required’ and to record it. This was available at this inspection. It was also required that confirmation is obtained from the local community or district nursing team that training for staff in administering the above medication ‘as required’ meets the standards of the health trust. Mencap had provided the training. This check is still needed. 178 London Road DS0000067252.V347396.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 adequate. This judgement has been made using available evidence including a visit to this service. The home takes account of residents’ views and procedures are in place to safeguard them but falling below assessed staff levels at time increases the risk to residents. EVIDENCE: The home has a complaints procedure though the needs of the residents are such that they would have difficulty in understanding the written or pictorial versions. Care plans indicate that residents wishes are taken into account and during the inspection visit staff were actively listening and responding to residents. At the last inspection it was a requirements that relatives and representatives are provided with a copy of the complaints procedure. One relative spoken with was not aware of the formal complaints procedure but all felt able to raise issues and feel that the home responds appropriately. The requirement has not been repeated. The home has policies and procedures for adult protection. Staff have access to training courses in adult protection. In the staff survey all said that they know what to do if residents have concerns about the home. As evidenced in the staffing section staff are given training in adult protection in induction. Two staff spoke about protection training and one asked was able to say what to do if an allegation was made. Staff levels are referred to in other sections of the report. As they are below the required number at times this increases risks to residents. 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 16 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a pleasant, clean, bright and spacious range of areas to live in. EVIDENCE: It was found at the last inspection that the physical environment had been specifically designed to cater for each person’s needs. The physical environment has continued to offer separate areas for residents and shared areas. The adaptations and alterations to the environment noted at the last inspection are still in place and continue to be in working order. Some damage was noted in the first floor bedroom and in the lounge. Staff said that that damage and maintenance needed is recorded and they were confident that it would be addressed. A folder is available for staff to record items for attention. This had been recorded in recently and all of the recorded tasks were ticked and signed as completed. Most but not all comments about fixing breakages were favourable. 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 18 In the AQAA the manager stated that some improvements had been made and there are plans to improve the environment such as making some walls more solid, finding a new television system that can be fixed in a safe position for one resident, and finding ways of limiting damage through challenging behaviour. The home is clean and laundry facilities are provided with a macerator for disposing of some clinical waste. The latter was out of order but staff said that they had use of yellow sacks and a clinical waste service to deal with this. They are provided with infection control training as part of their induction and they are provided with disposable protective items for infection control. 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst staff have good programme of training the staff levels required to meet residents needs are not provided at all times and this can increase risk levels at times. There is insufficient evidence in the home to demonstrate that the recruitment process protects residents. EVIDENCE: A copy of the review of staff levels was requested for observation to check that the requirement made in the last report had been met as then it had been found that a separate assessment of the staffing needs for each person had not been carried out by the home or with social services. The review was required to include the gender mix and general staff level at night taking needs and risks into account, and staff level to support needs in the community. The staff level review recorded as completed on 11/9/07 comprised of an assessment of risk and was not in sufficient detail to take the above fully into account. However, it did identify that all service users need a minimum of a 11 staff ratio in the house and identified a number of potential risks if this is not 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 20 provided. However, the staff levels have been reduced and a ratio of 1-1 is not always provided. At the last inspection it was noted that day time staff levels were a minimum of 4 staff on duty from 7am to 9.30pm each day with a fifth person for one service user from 10am to 2pm. The manager at this inspection said that this fifth person had been from the day services to work with a particular person and that this service had been stopped with negotiations underway with the care manager about funding. In addition, talking with staff and the manager it was noted that the staff levels had been reduced to three staff for each day shift but with a reduction to two a certain points in the evening when one staff member –referred to by staff as a floater -is required to assist at another care home. This was of concern to some staff particularly when the shift was including relief staff and their overall ability to respond to behaviours was decreased . The rota had not been adjusted to reflect that at times two staff are on shift. The issues of the staff reduction from 9.30 pm was not addressed in the staff level review. Although staff said that two of the residents choose to go to bed by 9.30 –10 pm only one waking night staff is on duty from 9.30 to meet the needs of anyone who is up. Staff also commented on the difficulties with noise when sleeping in and risks of working the next morning when tired especially if having had to get up. The requirement to review the staff level has been repeated and a new requirement made to ensure that staff levels assessed as needed, are provided. Verbal and written feedback from staff confirmed pre-employment checks are carried out before staff are employed. In the last inspection report it was required that staff records as detailed in Schedule 2 of the regulations must be available for inspection because records of recruitment were not in the home for relief staff. This had not changed at this inspection and records were also not fully in place for two other staff discussed. The requirement has been repeated. Staff have positive views about training offered. One thought that the training is ‘excellent’. Verbal and written feedback from staff indicated that they thought that staff induction covered what they needed to know fairly well. One staff member had received induction before working in the home and then had three weeks of shadowing to get to know the residents. Various training courses were attended in this time including epilepsy, first aid, POVA, food hygiene, infection control, respect and respond, and protect and respond and thought that training in challenging behaviour, team teach and autism was planned. The training had been recorded. The manager confirmed that this training was being planned. In general staff said that they received training relevant to their role and are kept up to date with new ways of working though two commented on needing 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 21 more information about policy changes and all said that they usually had the right support and experience to meet differing needs. In written feedback all said that say that the manager regularly meets with them and discusses their work. 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents’ benefit from a management that reviews and monitors progress of the service based on their needs and wishes with health and safety taken into account but this is currently being compromised by a reduction in staffing levels below the assessed need. EVIDENCE: It was noted at the last inspection that the manager’s qualifications include the NVQ 4 and the Registered Manager’s Award. She follows courses to update her and on the day of the inspection was at a health and safety course. Staff and relatives said that she is approachable and that they can raise issues that she will listen to. One staff member described her as ‘helpful’ and ‘effective’. Regular staff meetings are held. 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 23 There is evidence that aspects of the home are monitored. The staff have a health and safety file in which a number of monitoring sheets are completed regularly to show that for example, water temperatures, the fire system and alarms and wheel chairs are checked and showerheads are cleaned. Food temperature testing is less regularly carried out. There is a continuous improvement plan, which should be updated regularly, but this has not been done since August 2007 and the manager agreed it needed to be completed. The home had just received a service review by Mencap and the manager was waiting for the report to include action plans in the continuous improvement plan. The manager stated that she intended to do it the week after the inspection. She also said that satisfaction surveys of residents and relatives are planned to take place in February 2008. The management are not providing the staffing level assessed as needed in the homes own risk assessment and the outcomes for residents is a reduction in service and increased risk as identified in the sections on individual needs, lifestyle and staffing above. The manager stated that there had been fewer incidents reported recently and that staff needed to review how they were working with some of the risks. However, the reduction in the staff levels is not based on a clear assessment indicating that this is safe. 178 London Road DS0000067252.V347396.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 2 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 2 34 2 35 x 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 2 x x 2 x 178 London Road DS0000067252.V347396.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 YA13 Regulation 12(1)(a) Requirement Residents must be supported to be involved in the range of activities identified through the care planning process in order to provide them with adequate mental stimulation. Confirmation must be obtained from the local community or district nursing team that training for staff in administering bodily invasive medication meets their expectations. Any further instruction given must include an assessment of staff competence to meet residents’ needs. This is an amended requirement from the report of 8/2/2007. 2. YA33 18 A review of the staffing levels needed to meet the individual needs of each resident must be carried out taking account of their needs throughout the day and night. This is an amended requirement from the report of 8/2/2007. Assessed staff levels must be DS0000067252.V347396.R01.S.doc Timescale for action 27/11/07 1. YA20 13 06/12/07 06/12/07 3. YA33 18(1)(a) 27/11/07 Page 26 178 London Road Version 5.2 4 YA34 19 schedule 2 provided to ensure that residents’ needs are met at all times. Staff records as detailed in Schedule 2 of the regulations must be held in the home. This is an amended requirement from the report of 8/2/2007. 06/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 178 London Road DS0000067252.V347396.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 178 London Road DS0000067252.V347396.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. 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