Inspection on 11/05/06 for 26 Penkridge Road

This inspection was carried out on 11th May 2006.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

26 Penkridge Road 07/10/08

26 Penkridge Road 09/10/07

26 Penkridge Road 23/01/06

26 Penkridge Road 27/09/05

26 Penkridge Road 23/02/05

26 Penkridge Road 07/09/04

26 Penkridge Road 21/01/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 26 Penkridge Road Bedhampton Hampshire PO9 3LU Lead Inspector Ms Wendy Thomas Unannounced Inspection 11th May 2006 11:00 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 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 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 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. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 26 Penkridge Road Address Bedhampton Hampshire PO9 3LU 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) 023 9247 5911 www.c-i-c.co.uk Community Integrated Care Nora Jane Fowler Care Home 2 Category(ies) of Learning disability (2) registration, with number of places 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the category LD are only to be admitted between the ages of 18 and 60 years 23rd January 2006 Date of last inspection Brief Description of the Service: 26 Penkridge Road is a detached house with four bedrooms. It is registered to accommodate two adults with a learning disability. The registered providers are Community Integrated Care (CIC). Knightstone Housing Association manages the property. One service user currently lives at 26 Penkridge Road. They have lived there since it opened, until recently with another service user. 26 Penkridge Road is an unadapted house. It would not be suitable for people who use wheelchairs, or who have significant mobility or sensory needs. The house is on a hill overlooking Portsmouth and the sea. It is in a residential area. The service has a car to access local shops and other amenities. The fees for the home are £992.20 per week. This includes care, accommodation, food, an allowance for clothing and holidays. Chiropody and personal spending money are not included. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit to the home was unannounced and took place on Thursday 11 May 2006 at 3.30, and lasted three and a half hours. The member of staff on duty at the time of the inspection was the manager. The inspector spent time talking with her and the service user, studied paperwork, policies and procedures pertinent to the standards being inspected, and had a tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 6 Some of the information in the service user’s plan is well thought out, and recorded in a way that values the service user. However, it would be easier for staff to access if it were pulled together into one document with a logical order. The information has not been reviewed and updated adequately and some out or date information is still included. There were omissions in the recording of healthcare appointments. These should all be recorded and cross-referenced as necessary so that no follow up action is missed. There was no medication procedure. To avoid errors in administering service users’ medication, a medication procedure must be developed. Records containing confidential information were not being locked away. This is especially important when the home is unoccupied or there are visitors to the home who may pick up and read files. The home’s smoke detectors were not being tested. This puts the service user and staff at potential risk should they not be working if a fire broke out. Some internal doors were propped open. The manager was not sure which, if any, of these were fire doors. She must consult the fire safety officer to see if it is safe to prop them open so that the service user and staff are not being put at risk. 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. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 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 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The assessments and trial visits offered to potential service users enable them to be sure that the home could meet their needs. EVIDENCE: The manager reported that there are no plans to admit additional service users in the immediate future. The Community Integrated Care (CIC) admissions policy is available should it be needed. This was seen. It detailed the assessment process and details of funding. The manager said that in addition to this document, she would ensure that any future service users had a gradual introduction to the home with visits and preliminary stays prior to moving in. It was suggested that these details be added to the local admissions document. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. A more coherent and up to date individual plan would enable staff to more easily locate the information needed to support the service user appropriately. The service user benefits from staff supporting them to make valuing choices about what they do. EVIDENCE: The service user’s personal file was seen. This contained sufficient information for staff to gain a picture of the person and how to support them. This information was dispersed through different areas of the file such as the pen picture and the essential lifestyle plan. It is suggested that all this information is brought together into one up to date document so that staff can access information they need to know more readily. The essential lifestyle plan was dated 3 August 2004 and some of the information contained was not relevant anymore. The plan should have been reviewed sooner to reflect these changes. The manager explained that the 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 10 service user’s annual review had been delayed. However the care plans and risk assessments must always be kept up to date so that staff are aware of the current needs of the service user and how to meet them. A requirement is made regarding this. There was a wide range of risk assessments, some of which were well thought out. Risks identified included; the service user’s specific health and behavioural issues, medication, safety whilst out and about, and in the kitchen at the home. However these were dated December 2004 and were overdue for review. In some it was not clear why the issue was being considered a risk, others contained out of date information or needed more detail. A requirement is made regarding this. The service user and manager were asked how the service user is involved in making decisions about their daily life and the running of the home. It was explained that the most successful way to ensure that the service user participated in variety of activities inside and out of the home was to offer a small number of options for them to select from. The service user indicated that they enjoyed the activities that they were involved in and were satisfied with this procedure. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The service user benefits from one-to-one staffing and is able to participate in a range of activities and opportunities. Support from staff ensures that the service user receives a balanced diet and their rights and responsibilities are respected. EVIDENCE: The manager reported that now that there was only one service user living at the home, their quality of life had improved. They had more opportunities to go out and participate in a range of activities. The service user indicated their satisfaction with this. Before the inspection the manager and service user had been into Portsmouth and looked around the shops. The service user was pleased to show a purchase they had made. They said that they had had lunch out. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 12 The service user’s activities are recorded on a “daily evaluation sheet”. The records for the previous ten days were seen. The service user had been out everyday for such activities as drives, shopping, looking round shops, a healthcare appointment plus a snack out, walks along the beach and in a park, and trips to the local pub to play snooker or watch football. The manager reported that as well as travelling in the house car, public transport would sometimes be used. In house activities had included a wide range of activities that were appropriate for the service user. When discussing the garden the manager and service user described getting the garden furniture out, cleaning it and weeding the crazy paving. The manager did the weeding and the service user helped to pick up the weeds and put them in the bin. During the inspection a member of staff and service users from another CIC service came to visit. The service user at 26 Penkridge Road said that they were happy for the visit to go ahead. They were later observed chatting with one of the service users from the other service over a cigarette in the garden. The manager shared her perception that the service user was happier now that they were living on their own with staff support. She described how the service user engaged more with staff, appeared happier and participated more in activities and social interaction. She thought that the service user did not particularly want to live as part of a group. Most of the time staff are lone working. The manager explained that she would pick up any issues relating to the service users rights being restricted through daily recording, regular handover conversations with staff, observation of staff and from the service user themselves. Daily recording showed that a balanced and varied diet was provided. The manager explained that the service user always decided what they wanted for lunch, but for the evening meal they were offered a choice of two or three options. This way the service user still had choice but was supported to have a varied and balanced diet. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The service user benefits from support to access appropriate local healthcare support, however the lack of consistent recording and a clear medication procedure could lead to health matters not being followed up and medication being incorrectly administered. EVIDENCE: The support required by the service user in relation to personal care is recorded. The service user acknowledged that they were happy with the support they were receiving. The service user accesses local healthcare facilities and there were recording sheets containing details of some appointments. However not all appointments were being recorded and in some cases outcomes or follow up action were not recorded. It was therefore unclear if staff needed to carry out any follow up action. Medication changes had not always been wrritten on the service user plan. This could potentially lead to errors in medication administration. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 14 The service user’s healthcare needs were being met through an effective relationsip between the home and the specialist healthcare team. There was no medication procedure available. A procedure detailing how medication is stored, ordered, administered, recorded and disposed of must be produced. If it is not clear to staff the steps they must follow there is an increased likelihood that medication is administered incorrectly to the service user. It is recommended that the Royal Pharmaceutical Society of Great Britain’s guidance “ The Administration and Control of Medicines in Care Homes and Children’s Services” is consulted when compiling a medication procedure for the home. The medication recording was satisfactory and all medication from blister packs had been given. There was a bottle marked “refused med” with a number of tablets in it. These were not recorded in the returns book and although the manager thought she knew where they had come from there was nothing to document what they were or why they were being disposed of. The need for a clear audit trail of medication through the home was discussed and the manager agreed to develop this. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Systems are in place to ensure appropriate protection for the service user and to follow up any complaints. EVIDENCE: A statement about complaints was hung by the front door. There were various versions of complaints procedures in different files. It is suggested that only the up to date version is retained. The complaints log was seen and there had been no recent complaints. The manager confirmed that the service user’s advocate and family had been given a copy of the complaints procedure. The home follows the CIC policy and procedure for the protection of vulnerable adults. A copy of this was available in the CIC policies file. Other information regarding adult protection was also available. The manager reported that there was a whistle blowing policy in place. CIC have a policy for supporting service users with their finances. The manager explained that any withdrawals from service users’ personal bank accounts have to be authorised. Documents were seen confirming that the systems provided sufficient safeguards and the service user received appropriate support for managing their finances. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The service user benefits from a homely environment with comfortable domestic furnishings, which is kept clean and has a good standard of hygiene. EVIDENCE: The home was clean, tidy and hygienic at the time of the visit. The home consists of a large sitting/dining area, which was suitably decorated and comfortably furnished. The service user appears to spend the majority of their time in this area. There is also a good-sized kitchen suitably equipped for the needs of the home and service user. Downstairs there is a toilet, utility area and storage area. Upstairs there are four bedrooms, two unoccupied, one occupied by the service user and the other used for staff to sleep in. The décor of the upstairs bathroom is tired and dated and would benefit from attention, particularly the bath panel which looks battered. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 17 The service user’s bedroom was nicely decorated and furnished. It contained personal effects, which belonged to the service user. They agreed that they were happy with their room. Records showed that they often spent time there listening to the radio. There is an enclosed garden at the back of the house. This comprises a lawn surrounded by borders. Contractors cut the grass but the borders are in need of attention being somewhat overgrown. The manager reported that she and the service user had done a little gardening together, removing the weeds from between the paving. The service user indicated that he had enjoyed helping with this. It is suggested that if it is not possible for the staff and service user to maintain the garden to a satisfactory standard then other means should be sought to do this. There was a heap of old furniture stacked in the driveway. This did not enhance the appearance of the building. However following the inspection the manager confirmed that this had been disposed of. Previous inspection reports highlighted a need that the home had identified, to fit window restrictors to the upstairs windows. The manager reported that the window restrictors had now been installed. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The service user benefits from a staff team who have attended training sessions pertinent to their needs and who have been satisfactorily vetted by the organisation. EVIDENCE: Staff normally work on their own with the service user. At the time of the visit to the home, this was the manager. Staff work form 9am to 9am the following day, sleeping in overnight. There has been a lot of upheaval in the staff team in recent months. The home had been managed by an acting manager from another of the organisation’s homes, and then by the deputy manager at 26 Penkridge Road for a period of time. The home’s manager has now returned. She reported that since her return, all of the staff team have left and new staff are now in post. The manager has known the service user for the whole of the seven years they have lived in the home. They have an established relationship of mutual respect and friendship. Staff files for two members of staff were seen. Although they had only recently come to the home they were already employed by the organisation, so 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 19 had previously undertaken the company’s induction programme. There was evidence of Criminal Records Bureau disclosures, application forms, and two references for each. There was a section in their files for supervision notes. The manager said that formal supervision sessions happened approximately every six weeks. The organisation has provided the manager with training records, which include mandatory training and when this should be renewed, plus other training. The record identified that some staff needed fire training. Records seen suggested that other training such as food hygiene and first aid had been undertaken. Staff had been on a range of other courses relating to the organisation or the client group, such as appraisal training and crisis prevention and intervention. The deficit in fire training must be rectified. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is run to meet the needs of the service user, they are consulted and their opinions are taken into account. The service user’s privacy could be compromised due to records not being kept securely. Service user safety in the event of a fire would be improved with effective testing and use of equipment. EVIDENCE: The manager reported that there had been period of instability in the home because of changes within the staff team and her return after a period of absence. It had also been a difficult time for another service user who has now moved on. Their behaviour had posed challenges the staff team found 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 21 difficult to manage. There is now a new staff team in place and the manager reported that staff morale had improved. The manager explained that she was studying for NVQ level four in care and the registered manager’s award. The manager has a very hands on approach and is valuing in her approach to the service user and committed to their welfare. The need to ensure up to date records regarding the care of the service user was discussed and aspects of the manager’s role. The manager stressed the importance of providing time and support for the service user, yet the difficulty in maintaining this with one member of staff not avialable. The need to take action to ensure that the service user’s needs were supported and promoted whilst implementing her management responsibilities was discussed. It was noted that while the staff and service user were out of the house files containing confidential information relating to the service user, theirs and the home’s finances were left out in the sitting/dining area and the office. This information must be kept securely and a requirement is made regarding this. It was observed that notes from service user meetings were kept. The manager explained that these took place every four to six weeks. The notes confirmed this. The manager was not aware of the quality assurance processes used by the organisation. This information was provided in a follow up phone call to the service manager. They said that all the CIC services have a business plan. Monitoring of the quality of the service is carried out via monthly visits to the home looking at the standard of care, the state of the premises and events occurring in the home, three-monthly monitoring of the service user’s views about the home, and annual questionnaires sent to service users, their relatives and sponsors. The effectiveness of complaints and other procedures are also monitored. It was explained that the organisation is currently looking at how this evaluating of the service can be developed and linked to producing plans and strategies for service improvement. The health and safety records for the home were seen. There was evidence that fire fighting equipment and thermostatically controlled valves on taps had been serviced. A landlord’s gas safety certificate and fire drills were up to date. New smoke alarms had been fitted several weeks prior to the visit. These were not being tested. This must be done to ensure they are working properly and lives will not be put at unnecessary risk should there be a fire. Several doors were propped open that appeared to be fire doors. The manager was not sure which doors were classified as fire doors. Therefore a requirement is made that she contact the fire safety officer to discuss this. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 22 At the last inspection cleaning materials were found to be stored in an unlocked cupboard. New locks have been installed on the cupboards but they did not provide sufficient security and therefore arrangements must be made to ensure that cleaning materials are stored securely. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 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 X 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 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X 2 2 X 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 13(4)(b) 14 15(2)(b) 13(2) 17 23(4) Requirement The service user plan must contain up to date information including details about the person, how staff support them, and how risks are managed. A medication procedure must be produced and followed. Individual records and the home records must be kept securely. Fire safety standards must be maintained. The smoke detectors must be tested weekly and the advice of the fire safety officer must be sought regarding which internal doors can be propped open. All staff must have fire training at least every six months. Timescale for action 11/07/06 2 3 4 YA20 YA41 YA42 11/07/06 12/06/06 11/07/06 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 Good Practice Recommendations DS0000011977.V289126.R01.S.doc Version 5.1 Page 25 26 Penkridge Road 1 Standard YA19 Records of all contact with healthcare professionals should be kept including any outcomes or further action that is needed. 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 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 26 Penkridge Road DS0000011977.V289126.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!