Inspection on 04/10/07 for 182 Bromham Road

This inspection was carried out on 4th October 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

182 Bromham Road 08/10/08

182 Bromham Road 26/04/07

182 Bromham Road 25/10/05

182 Bromham Road 14/06/05

182 Bromham Road 25/10/04

182 Bromham Road 12/05/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 182 Bromham Road Bedford Bedfordshire MK40 4BP Lead Inspector Andrea James Key Unannounced Inspection 4th October 2007 10:00 182 Bromham Road DS0000014886.V350180.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 182 Bromham Road DS0000014886.V350180.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. 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 182 Bromham Road Address Bedford Bedfordshire MK40 4BP 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) 01234 357238 F/T 01234 357238 no email as at 02.07.07 Lansdowne Care Services Mrs M Hoath Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th April 2007 Brief Description of the Service: 182 Bromham Road is a large Victorian House situated on the west side of Bedford. It was registered in 1996 to provide residential care for 6 adults with learning disabilities. The home currently has 5 people using the service. There are six single bedrooms on two floors and toilet and bathing facilities on both floors. The communal space, comprising of a lounge, dining room and activity room are on the ground floor as is the domestic style kitchen and utility room. There is a spacious garden to the rear. The home is conveniently situated for access to Bedford with all its amenities and bus and rail services. Weekly fees for accommodation were between £928.91 and £1228.52. this did not cover the cost for toiletries, holidays and personal items. 182 Bromham Road DS0000014886.V350180.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 carried out 5 months after the last key inspection. The inspection lasted for the duration of 5.5 hours and the manager was present for throughout the inspection process. The inspection followed a case tracking methodology where a sample of people using the service were selected and their files inspected, where possible their key workers were spoken to. The inspector used observations to ascertain what it was like for people living at the home as the users communication skills and understanding of the inspection process was limited. The report also consists of information received from the home AQAA (Annual Quality Assessment audit). The inspector would like to thank the care staff, the manager and people using the service for their co -operation in the inspection process. What the service does well: The home created a warm and welcoming feel to those using the service and people that may visit. The organisation ensured that the home was kept in good decorative state and maintained satisfactory levels of care to people using the service through their staff retention and stability of the management structure. The staff team were also trained and qualified in meeting the varied needs of the users. The home had a robust care planning structure that highlighted the various aspects of users personal care, health care and mental assessments carried out with the co- operation of external professionals. The people living at the home were able to have a fulfilling life style by the various activities undertaken for individual users of the service, both in-house and within the local community. People using the service were encouraged where possible to hold their own monies and were supported to access the community in shopping trips, leisure trips and visiting relatives. People using the service were also encouraged to have holidays and various celebrations such as birthdays. 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home should ensure that: • • All records relating to the authenticity of staff members working are kept at the home for inspection. All staff receives health and safety training as a part of their mandatory training programme. All users of the home have a suitable lockable facility in their bedrooms in which to store valuables. That all fire regulations are maintained at all times and doors are not propped open. Care staff are vigilant in signing medication charts. Procedures are implemented within the quality assurance policies that seek to monitor the views of people using the service. • • • • 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. 182 Bromham Road DS0000014886.V350180.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 182 Bromham Road DS0000014886.V350180.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): 1,2 &5. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to the service. The people using the service were presented with a Service User Guide and a Statement of Purpose, their was also evidence to suggest users received a comprehensive assessment of need and contractual agreements were presented in a pictorial form and signed by users, as a result users were well informed about the service they would receive. EVIDENCE: The home had clear procedures for admissions and files inspected suggested that users received a comprehensive assessment prior to admission and this process continued once the user was admitted to the home. The inspector was informed that because of intensive assessment one user had to be moved, as the home could no longer meet his medical or physical needs. Three case files were seen at this inspection. Each contained detailed evaluations of need that covered personal, sensory, social and healthcare needs. Other professionals had contributed to these assessments and the records indicated that people had been consulted about their needs and wishes. 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 9 The home ensured that users had access to a Service User Guide and a Statement of Purpose that detailed the resources available to the them. The manager demonstrated that these documents were kept under review and the Service user Guide was in the process of further changes to reflect current practices. The people using the service received individual contractual agreements that were signed, dated and presented in a pictorial format suitable to the needs of the people using the service. 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9. People who use the service experience an excellent quality outcome in this area. We have made this judgement using a range of evidence including a visit to the service. Satisfactory policies and procedures were in place to ensure users assessed needs were reflected in their care plans and where possible they were consulted about and enabled to take risks in maximising their independence, as a result users needs were met effectively. EVIDENCE: The care plans reviewed showed how the home was proactive in meeting the users needs. There was evidence that areas that needed further clarification and guidelines were written in plain English and staff spoken to were all knowledgeable about the changing needs of the people using the service. All care staff spoke of one user that continued to challenge the service and the inspector case tracked this user and could audit all the various records, meetings assessments, monthly reports, doctors’ notes, behaviour charts, 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 11 analysis of behaviour ratings, professional meetings, risk assessments and several guidelines recorded in the care plan documentation. The manager spoke at length of the various measures she and her team had implemented to ensure all users received the best care. One carer took the time to carry out personal research on possible triggers of the user’s behaviour. The home carried out various risk assessments and could evidence the opportunities given to all users to access the community and participate in all activities within the home. One carer described how a user communicated his needs and how the home accommodated the request. It was also noted that where users refused a task other opportunities were provided for them in the event that the changed their minds. The home held regular residents meetings, and for user who could not communicate advocates and relatives were invited to speak on their behalf. 182 Bromham Road DS0000014886.V350180.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): 11,13,14,16. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Procedures were in place that ensured people using the service received sufficient support to achieve and live a fulfilled life, as a result users were able to maximise their independence in all areas. EVIDENCE: From the records inspected and through lengthy conversations with several staff members the inspector was able to conclude that people using the service received the opportunities they needed to live a fulfilled life style. The inspector was informed and saw evidence to suggest users were able to go on holidays, visit relatives, attend day centres and have sessions in the community such as bingo. One user was also enabled to manage his own personal allowances and staff enabled users to assist in various shopping needs for the home. There was evidence to suggest that the home treated users equally irrespective of their cultural backgrounds. 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 13 Records and conversations with staff indicated that people living in the home attended day care facilities where activities were provided to retain and develop self-caring and independent living skills. The inspector was told that the day care services were provided by the Local Authority and also by the organisation at another site. Case files contained frequent reports from the day care service provided by the organisation that were incorporated into the review of overall care and progress. The inspector observed the day centre staff and the staff from the home working collaboratively in meeting one user’s needs that posed challenges and it was evident that all concerned had read and understood the guidelines implemented for the user. It was concerning however that the user who had limited communication skills, was clearly unhappy to return to the home and this negative behaviour had prolonged for several months had not been actioned by the placing authorities despite the home’s efforts. Information about events and places of leisure were posted in the home. Members of staff confirmed that people were taken out on a one-to-one basis so that the activity could be tailored to meet the users interest. 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 & 21. People who use the service experience an adequate service. This judgement was made using a range of evidence to include a visit to the service. Satisfactory procedures were in place that ensured the health care needs of people using the service were met but further development was needed to ensure procedures for recording medication is adhered to at all times, as a result of omissions users could be at risk. EVIDENCE: The inspector observed that carers treated people using the service with respect and dignity. All users had a locked door that care staff respected and would knock when they were occupying their rooms. The care staff spoke to users with a sense of humbleness and respect. The carers spoke of the users with a great sense of warmth and care and communicated with them on a level that they could understand. Staff spoken to said they were learning “Makaton” signing in order that they could further develop their communication skills with the users. Other carers spoke of understanding when to leave a user and return to them when they were in a better frame of mind to communicate. 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 15 The home is currently finding it difficult to meet the emotional needs of one of the users, as her behaviour have been challenging the service for over 12 months. The home have reported the situation to all the external professional bodies involved and have implemented extra measures in house that is within their power but felt frustrated that the appropriate authorities are taking a long time to react to the fact that this user needs are not satisfactorily met. It was also concerning that other users are also being affected as the behaviours when displayed have been physical to both users and care staff within the service. The records inspected showed 20 incidents since August 2007 to the date of the inspection. Staff commented that the situation as it stands is “an accident waiting to happen” as they are merely containing the situation. Other staff also reported that some users in the home have become withdrawn because of the unpredictability of the user when she challenges. A member of staff commented that she had her hair pulled while writing reports and this was concerning for safety reasons. The inspector was concerned that the home was only registered for users with a learning disability and the resources are not available to meet the needs of people who pose such a challenge to the service. The home had satisfactory policies and procedures in place that ensured the safe receipt, administration and disposal of medication. The stocks inspected were safely stored and in good order. Records indicated that staff had received training on medication before they were allowed to administer medication to people using the service. Care staff spoken to all appeared knowledgeable about ordering and disposal of medicines. The MARS (Medication Administration Record Sheets) were used appropriately but there was a need to ensure that signatures of staff are obtained at all times when medicines are administered. The inspector observed that 6 omissions of signatures were seen for the month October 2007. Care notes inspected showed that changes in needs as people aged had been taken into account. The inspector was informed that one user recently left the home because his physical and medical needs had changed and the home could no longer care for him. The transition was still in line with meeting the user needs and finding the care that best met his needs. 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. Satisfactory processes were in place to ensure the views of users were heard and they were protected against abuse. EVIDENCE: The home had satisfactory procedures in place to ensure that issues that affected the well being of people using the service were reported using the correct procedures. There was evidence that one of the users had been challenging and caused harm to other people using the service. The manager and staff team ensured that the abuse procedures were implemented. There was also evidence to suggest complaints would be dealt with in a satisfactory manner. Staff spoken to said they were aware of the Complaints and Safeguarding procedures and there was evidence to suggest that some staff received training in the Safeguarding of Vulnerable Adults. Records were seen in relation to personal monies held on behalf of three people. Records of income and expenditure for day-to-day expenses had been well maintained. Purchases were substantiated by receipt. Records of cash balances tallied with the actual amounts held in a locked safe. The proprietor held the savings accounts for people. 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 17 The home has made improvements in their ability to maintain staff records but further development was needed. The inspector identified three care staff that failed to have satisfactory information on their records to ensure the users safety. The inspector identified that there was a lack of criminal record bureau check numbers for several staff and work permits were missing for two of the care staff. The manager was able to contact the head office and had the information faxed during the inspection. The inspector was therefore able to identify the staff authenticity but it was concerning that the home had not obtained these information since the last inspection. 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28 & 30. People who use the service experience a good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to the service. The people living in the home were provided with a safe and comfortable environment that was suitable in meeting their needs, as a result users environmental needs were being met. EVIDENCE: The inspector was given a guided tour of the environment, which appeared clean, and of a high decorative standard. The decorators were seen redecorating a bedroom that had been made vacant by a user who recently had to leave the home due to medical needs. The bedrooms seen showed that users were able to have their rooms decorated to individual preferences and all showed that users were able to have personal possessions, such as music and televisions in their bedrooms. 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 19 It was concerning however to note that these rooms failed to provide a lockable facility to ensure users could store their valuables and promote their independence. Systems were in place to monitor equipment and the environment as a whole to maintain a safe place to live and work in. Individual risk assessments were in place for assessing people living in the home in areas of equipment that could result in injury. Similarly, risk assessments for safe working practice within the building were also in place. Visual checks confirmed that electrical goods, a hoist and fire extinguishers had been regularly maintained. The communal areas of the home were well light and of a good decorative standard but there was a need to ensure doors are not propped open in adhering to fire regulations. 182 Bromham Road DS0000014886.V350180.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): 31,32,33,34,35,36. People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence including a visit to the service. Satisfactory processes were in place to ensure the safety of people using the service through recruitment, training and supervision, however further development was needed to ensure all staff records are held at the home that clearly shows care workers status, as a result users could be at risk. EVIDENCE: The home had a stable staff team that were experienced and knowledgeable about the needs of people living at the home. They all had key clients that they were responsible for and the carers spoken to spoke passionately about the care they provided to the people using the service. A large percentage of the carers had achieved their NVQ level 2 and above in care and all had a training programme that detailed mandatory training and other trainings undertaken in meeting the changing needs of the people using the service. There was also evidence to suggest carers received an induction when they commence their employment and all received supervisions and staff meetings on a monthly basis. Staff spoken to said they received monthly supervisions. 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 21 Rotas seen suggested that sufficient numbers of staff were rostered on duty to care for people living at the home. The inspector was informed that an additional member of staff was also rostered on because of the challenges posed by one of the user. The manager also reported that they had interviewed 2 potential employees but were waiting for satisfactory clearances, before they could commence their employment. This would make the home fully staffed. The inspector viewed all the staff files held for the carers who worked at the home and although improvements have been made to the standard of records kept at the home in meeting the requirement of the last inspection further development was needed to ensure all records kept were in line with schedule 2 of the National Minimum Standard. There was evidence to suggest that robust recruitment procedures were in place and the carers selected were able to meet the needs of the users the home was registered for. There was evidence to suggest care staff had regular staff meetings and staff spoken to said the home operated an open door policy and they were able to speak to the manager whenever they wanted. 182 Bromham Road DS0000014886.V350180.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): 37,38,39,41,42. People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence including a visit to the service. Satisfactory processes were in place to ensure people using the service benefit from a well run home and that the best interest of the users are safeguarded, however further development was needed to ensure better monitoring, recording and safety of the users are maintained. EVIDENCE: The home had a stable management structure that created an environment that both carers and people using the service were able to feel safe. The manager appeared confident and knowledgeable about the needs of the team and the people using the service. Carers spoken to said they felt supported by the manager and felt able to approach her should they have a problem. When staff were asked to describe the manager they said “good”. 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 23 The home had developed some aspects of quality assurance for people using the service through their ability to identify maintenance issues around the home, have annual redecorative plans for users bedrooms and key workers monthly chats with users of the service where views and requests are sought, however further development was needed to ensure the views of people using the service are sought in a structured way that will help to develop the service. There was no evidence that the views sought were analysed and published in accordance with the requirement of the standard. There was also a need to ensure the care staff are trained in Health and Safety to ensure they were aware of the procedures to follow in maintaining the users safety. The inspector identified that 2 main doors were propped open with chairs, which contravenes the fire regulations and could put users at risk. The home had satisfactory fire procedures for safeguarding users in the event of a fire. The inspector saw weekly alarm tests, emergency plan of action, fire risk assessment that was approved by the fire authorities, fire drills and evacuation procedures. The home also had annual fire alarm inspections the most recent being the 6th of July 2007. The recording procedures in the home were in general terms satisfactory but further development was needed to ensure staff details are satisfactorily recorded. The care staff spoken to said they were aware of the policies and procedures of the home and the manager was able to demonstrate that all care staff had read the policies and procedures each time changes had been made or new policies and procedures had been implemented. 182 Bromham Road DS0000014886.V350180.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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 2 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 3 x LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 X 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 3 3 3 1 X 2 1 3 182 Bromham Road DS0000014886.V350180.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 YA19 Regulation Requirement Timescale for action 30/11/07 2 YA20 3 YA25 4 YA39 5. YA41 12 (3) Arrangements must be made to and 13 (c) ensure that the user that presently challenges the service is assessed and her needs along with the other users are met satisfactorily. 13 (2) Arrangements must be made to ensure the signatures of all medicines administered are recorded on the Medication Administration Record Sheets. 23 (2) Arrangements must be made to (m) and ensure a lockable facility is 16 (2) (l) available for all users in their bedrooms. 24(1) Arrangements must be made to ensure effective quality assurance systems are in place that seeks to monitor the views of users of the service and that these are analysed and published in line with the standard. 17(2) The registered person must Schedule maintain detailed personnel 4.6 records on the premises. This must include the written application for employment and proof of identity. 30/11/07 30/12/07 30/12/07 30/11/07 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 26 Previous timescale:31/05/07. 6 YA42 13 (1) (C) and 23 (4) (a) Appropriate measures must be taken to address the fire doors that are propped open in the communal areas of the home. 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA35 Good Practice Recommendations Arrangements should be made to ensure all staff are trained in Health and Safety as part of their mandatory training needs. 182 Bromham Road DS0000014886.V350180.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 182 Bromham Road DS0000014886.V350180.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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