Inspection on 22/03/07 for 3-4 Cuthberts Close

This inspection was carried out on 22nd March 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3-4 Cuthberts Close 04/02/09

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 3/4 Cuthberts Close Queensbury Bradford BD13 2DF Lead Inspector Pamela Cunningham Unannounced Inspection 22nd March 2007 10:00 3/4 Cuthberts Close DS0000068477.V331774.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 3/4 Cuthberts Close DS0000068477.V331774.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. 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3/4 Cuthberts Close Address Queensbury Bradford BD13 2DF 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) 01325 373700 www.sjog.co.uk Saint John of God Care Services Mark Dennis Bradfield Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New Service Brief Description of the Service: The home is purpose built for this service and opened in March 2005. It is situated in Queensbury, on the outskirts of Halifax and Bradford and is within walking distance of the local shops, chemist, pubs, fish shop and post office. There is a local bakers shop that the residents like to use and supermarkets within a short driving distance. The home, which provides nursing care for people with sever learning difficulties and challenging behaviour receives excellent support from the local GP practice that has proved to be very helpful to the service. The home is built next to another home belonging to the same organisation and is close to others in the area. One side of the home overlooks allotments that are used by the local community. The home is divided into two sections. Accommodation is provided in eight single rooms all with en suite facilities. There are lounge and dining areas on each side with a large area in the middle where the office is situated. There are ramps to the front of the building and a decked area to the side nearest the allotments. Parking for the home is roadside only and very limited, and there is no garden space available. There is however some decking to the side of the home where residents can sit in good weather. At the time of writing this report the fees charged for care provided were£1621 per week. 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One visit was made to the home on 22nd March 2007. This was the first inspection since it was re-registered. The home did not know that this was going to happen. Feedback was given to the manager during and at the end of the visit. The purpose of the visit was to make sure the home was being managed for the benefit and well being of the residents. Before visiting the home the inspector asked for information from the manager (the pre inspection questionnaire – PIQ) which asks about what policies and procedures are in place and when they were last reviewed, when maintenance and safety checks were carried out and by whom, menus used, staff details and training provided. Comment cards were sent to the home to be given to their relatives’ to find out what their views of the home were. At the time of writing this report one comment card had been returned, and the written comments were very favourable. The relative wrote” My grandson always seems happy and well cared for. As he can’t speak. I have to assume he is content. I only hope he will always be well cared for. In order to find out how well staff knew residents, care plans were looked at during the visit and residents and staff were spoken to. Other records in the home were looked at such as staff files, training records and complaints received. What the service does well: Staff continue to form firm relationships with the residents, and spend time with them doing things they enjoy. Where it is suitable, this is done on a one to one basis. Staff were seen to be doing this at the time of the inspection. The home receives excellent support from the local healthcare team and outreach services, and there is no problem with asking them to visit the home. All the residents apart from one attend some type of day care. Care staff are working on NVQ level 2 or 3, and qualified staff are able to keep up with PREP. (Registration requirements) All staff attend any mandatory training courses and there was evidence to prove this had taken place. There is an awareness of health and safety amongst the staff team, and certain staff said they feel well supported by their manager. 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 3/4 Cuthberts Close DS0000068477.V331774.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 3/4 Cuthberts Close DS0000068477.V331774.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, 3, 4 and 5 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Parents and carers of the residents have enough information about the home to decide if it will meet their needs. EVIDENCE: The service user guide and the Statement of Purpose have recently been reviewed by the company in light of the recent change in registration. Copies have been sent to the Commission and are appropriate. Pre – admission assessments of needs are done which include everyone who has been involved in the care of the resident such as, social workers, district nurses and physiotherapists. This way a holistic approach can be made when planning care. This is good practice. Home visits are also made when necessary and involve the resident if possible, near relatives and main carer. Trial visits to the home are made depending on the residents needs. Advocacy services are used if trial visits are not possible. Contract of residency are in place, however the section regarding what the resident has to pay for that the fees do not cover was not documented. The contracts seen were also not signed by the parent/carer. The manager said not all residents have near relatives. In those cases it should be clearly stated, and the contracts signed by an appropriate person on their behalf. 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 9 The manager said the staff are able to assess whether they can meet their needs and aspirations of the clients by continuing assessment of their behaviour, and their reactions to the home and facilities. Support staff spoken to during the inspection said, “It can be very hard, the longer you know your residents, the better you are able to read them” 3/4 Cuthberts Close DS0000068477.V331774.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): All standards were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents care needs are met and this is fully documented in the ILP’s (Individual life plans - care plans.) EVIDENCE: Care documentation, Individual life plans (ILP’s) of four residents was reviewed. All contained a pen picture of the resident, a health history and life history. This is known as the “get to know me document” There was evidence in these documents that they had been recently reviewed. All care plans were linked to risk assessments where a risk to the resident had been identified. All care plans were dated when the care was prescribed, and the risk assessments of certain residents were complete with the action taken to minimise the assessed risk. 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 11 All care plans are complete with outcomes identified, and full signatures are now present of the nurse prescribing the care. Outcomes of reviews are also recorded so that any improvement or deterioration in clients’ conditions is recognised when the next review is done. Evidence was also seen of dental, optical and foot care, and where appropriate evidence of medication and psychiatric reviews. The emotional needs of the residents are met by discussing problems with families, especially at end of life situations. The manager said every attempt is made to help the resident s make decisions about their lives, and take part in all aspects of life in the home. This is done by holding parent/carer meetings and making the resident as fully involved in the proceedings as their abilities allow. He also said their rights and responsibilities are the same as for any member of the general public, however the last meeting had to be cancelled due to an outbreak. All risks taken by the residents are allowed within a risk management framework, and this was fully evidenced in the care plan documentation. 3/4 Cuthberts Close DS0000068477.V331774.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): All standards were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to participate in social and leisure activities, be part of the local community and to maintain links with their friends and family. Nutritional needs are identified and special cultural dietary requirements met. EVIDENCE: All residents have activity sheets. These were completed and provided a clear picture how residents spend their leisure time both inside and outside the home. Care plans are now in place with instructions on how to deal with the specific hygiene needs of the female residents, and what assistance they need. The manager said one activity, which is a week in Bridlington is broken down into two sets of two nights, and one resident is being tried to see how he copes with a night away from home before a holiday is arranged. 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 13 Another activity arranged is a holiday to France for four residents. Two residents were out on a bus trip on the afternoon of the visit, and six residents were out at day care to New Ridge, which is a facility specifically for residents with learning difficulties. New Ridge staff care for the residents during this time. Families and friends are free to visit at any time without any restrictions. Cultural needs of residents are met. This was evidenced by information seen regarding one resident of the Muslim faith. The family have expressed a wish to take her to Mecca. Therefore, to see if it can be established if she can cope with a change of environment, she is being taken to Bridlington for three days. The manager said mealtimes are very much dictated by the residents needs, and depend very much on what time the residents get up, unless they are out at day care, then the normal time for the first meal of the day is around 8.30am. Lunch is between 12 and 1 pm and tea at approximately 4.30 to 5pm, depending very much if trips out are arranged. They are also offered snacks and rinks throughout the day, and supper at around 7.30pm. There are no residents at this time who are capable of helping with food preparation, however one resident is being encouraged to develop in this way, and is supervised using a plastic knife. The food preparation area was clean and well ordered. Food is regularly probed to make sure satisfactory temperatures are achieved, and all food in the fridges is labelled with the date it was opened. The home had a visit from the Environmental Health (Health Protection) agency on 06/10/06 and was congratulated on certain documentation. 3/4 Cuthberts Close DS0000068477.V331774.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): All standards were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service The home is able to meet the health and personal care needs of service users. The physical care needs are identified and monitored. EVIDENCE: The home uses only one local health centre who they have a good relationship with, and from whom they receive a good service. The manager said the religious needs are addressed, as many of the qualified staff are Brothers of The Order. The manager has had training in Death and Bereavement, and has identified a training need for all the staff team in this subject, however this has not yet been cascaded down to the care staff. Physical needs of the residents is met, and this is evidenced in the care documentation There are no clients in the home who are capable of administering their own medication; the nursing staff administer this on their behalf. 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 15 The home uses a monitored dose style of medication control. Each resident received their medication from heat sealed blister packs sealed by the Lloyds pharmacy. The system is safe, however the home needs to check the packs thoroughly as two tablets instead of one were present in one blister for one male resident. The home also has a contract with the supplying pharmacy for returning any unwanted/unused medication. 3/4 Cuthberts Close DS0000068477.V331774.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): Both standards were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service Residents and their relatives have their views listened to, taken seriously and action is taken to resolve issues and are protected from abuse from staff, and other people entering the home. EVIDENCE: The complaint procedure available for residents’, visitors and families, which is displayed in the office, is now appropriate. Staff receiving adequate training, including training in how to handle challenging behaviour, however it is not always possible to guarantee residents are protected from physical abuse from each other, due to the nature of the client group the home is registered to provide care for. Staff try to make sure this is achieved by close monitoring of situations when certain residents display aggression towards each other. The manager said residents’ rights are protected by the use of advocacy services when needed, and by providing adequate training for the staff, by good record keeping and by the involvement of others involved in their care. 3/4 Cuthberts Close DS0000068477.V331774.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): All standards were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offers a clean safe environment for the residents, promotes independence, and provides appropriate bathing and toilet facilities. EVIDENCE: The home is divided into four areas. I toured the building. The premises were clean and free from any unpleasant smells. House 4 has been provided with a new carpet, and the entrance from the main door has been provided with new solid built in shelving that can withstand the damage caused by certain residents because of their challenging behaviour. The lounge in this area has hard surface floor covering which is easier for the residents to walk on, as many of them are unsteady on their feet when walking about. It is also easier to maintain as spillages are more easily dealt with. 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 18 The large television in this part of the house is housed in a substantial safety cupboard. This is to prevent those residents with unpredictable behaviour having access to it and so saving them from harm. The home has provided window blinds for privacy, and to prevent certain residents pulling them down from the window, have positioned them inbetween the double-glazing. This area has also recently been redecorated, and furniture in the dining area is also due to be replaced. A sensory area has also been developed in this area for the benefit of one resident and paid for by his money. For certain reasons this is not able to be kept in the residents own room, so discussions have taken place between the next of kin and the senior staff to allow this to be sited in its present place, and therefore be of therapeutic benefit to all the residents’. The floor in this dining area has been replaced by antico hard flooring due to the previous floor “lifting” and therefore becoming a hazard to residents. Room 4 appeared very bare and void of any personal belongings of the occupant. When questioned the manager said, due to the resident’s unpredictable behaviour, it had been decided not to place anything in the room that could cause him harm. This has been done using a risk management process and is written in the care documentation. Two rooms including one bathroom in this area were quite cold. The manager said this was due to problems with the under floor heating in this area of the home and that plans had already been made to rectify it. House three has a very comfortable lounge and dining area. There is also special sensory equipment in certain other rooms in the building, which have been bought by the resident’s for their sole benefit as they spend time in their rooms. The fly screens in the kitchen in this area need attention, as they do not fit very well. This could lead to flying insects entering the food preparation area and contaminating food being prepared. All other areas in the home were visited, were free from any clutter that would be a risk to the occupants and were very clean. There is sufficient shared communal space in the home, and residents have the specialist equipment they need. 3/4 Cuthberts Close DS0000068477.V331774.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): All standards were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff clearly demonstrated awareness of the individual needs of residents. Staff are trained and competent to do their jobs. EVIDENCE: On the day of the inspection, there was enough staff on duty, and of sufficient skill mix to meet the special care needs of the residents living at the home. Staffing appears stable. Rotas identified that staff work long days, 7.45am until 9pm. This was queried with the manager who said he appreciated why I was questioning the long hours on duty, considering the complex needs of the residents living in the home, that the staff might need regular breaks from duty. He said the staff have formal breaks and also the opportunity to take other unofficial breaks if they are feeling stressed. This was confirmed by speaking to the staff on duty. The home also has an extra support worker on duty to give one-to-one care to one resident who is needing more input to his care due to recent changes in his medication following a care review. (This is good practice) 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 20 The deputy manager and the manager said the staff employed at the home are quick to recognise any problems and therefore take appropriate action, and said the residents recognise and benefit from the clearness of staff roles by the tasks the staff perform. This was evidenced by one resident approaching a support worker, and indicating he wanted a drink. Although the support worker was not the main carer of the resident, it was clear he knew the resident well enough to understand his needs. One staff member told me he had three weeks induction and that the training was “superb”. He said he gets to know what has happened with the residents at the handover period from the nurse in charge, and due to the “routines“ the residents are used to, he knows which area he will be working on, and which resident he will be caring for. (Residents who have learning difficulties or disabilities become very easily upset if their normal “routine” is altered in any way.) He said he gives total care to the residents he is key worker for except for the giving of any medication which the qualified staff give. He said he was aware of POVA (Protection of Vulnerable Adults) and had received training in this area, and is having formal supervision. Training records were inspected and identified staff were receiving formal supervision. All staff with the exception of 2 are up to date with fire safety training, and all staff have received instruction on the safe handling of residents. Other training such as breakaway techniques is also provided, and all staff have had abuse awareness training. As all staff are involved with food preparation, all staff have received food hygiene training. Recruitment documentation was reviewed and was found to be a robust process. 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): All standards were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager has the skills and knowledge to provide effective leadership. The home is managed well. EVIDENCE: The home is managed and run by an experienced first level registered nurse who has successfully completed the registered managers award. A very able deputy manager who is on secondment from the Learning Disability Healthcare Trust supports him in this role. The leadership and management of the home is one of an “open door“ way of life that benefits the resident, the staff, and visitors. This way the staff are assured that the manager is always on hand to ask advice from on anything they are not sure of, the residents, even with their lack of understanding know 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 22 he is there in the home, and the visitors be they parents or carers can feel safe in the knowledge there is someone in the home who is leading the team. Staff who work under his direction said they received good support from him and the deputy, and that the like working at the home. Policies and procedures are up to date, and with the exception of the adult protection policy are in line with relevant legislation and are accessible to staff. The Adult Protection policy however needs re visiting as it states, “do not confront the abuser”, as this gives the impression that staff must not get involved if they see or suspect abuse is happening in the home. The level of understanding clients have, makes it difficult to assess whether they are confident their views support all self-reviews and monitoring in the home. To ensure they are involved with the running of the home, parent/carer meetings are held, although of late they have not been well attended. The manager said health and safety in the home is constantly under review, and documentary evidence was seen of provision of and attendance of all staff for mandatory training. Management accounts are forwarded to the Commission. The home is part of a “not for profit” organisation. Regulation 26 (provider monitoring) visits are soon to be done by managers from other care homes in the care services. Currently they are being done by the deputy to the area manager. A risk assessment for the building has been done. 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 2 3 3 3 2 3 3 3 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 24 New Service 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 YA5 Regulation 5(1)(b) Requirement The registered provider must ensure contracts of residency are complete with what the resident is responsible for paying for, and that the contracts are signed in agreement. The registered provider must ensure all blister packs containing medication are checked for accuracy. The registered provider must ensure all staff receive training in end of life situations. The registered provider must ensure the fly screens in the kitchen area identified in the main body of the report are adjusted to fit properly. The registered provider must ensure the care services Adult Protection policy is amended Timescale for action 22/06/07 2. YA20 15(2) 22/06/07 3. 3. YA21 YA30 18(i)(c)(i) 13(4a&c) 16(2)(j) 01/09/07 22/06/07 4. YA41 12(1) 22/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 25 No. 1 Refer to Standard Good Practice Recommendations 3/4 Cuthberts Close DS0000068477.V331774.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. 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