Inspection on 15/05/08 for 30 Newland Street

This inspection was carried out on 15th May 2008.

CSCI found this care home to be providing an Adequate service.

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

30 Newland Street 17/05/07

30 Newland Street 19/12/06

30 Newland Street 12/09/06

30 Newland Street 07/03/06

30 Newland Street 27/09/05

30 Newland Street 09/02/05

30 Newland Street 16/09/04

30 Newland Street 13/02/04

30 Newland Street 12/11/03

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Alfred House Residential Care Home

Barkerhouse Road (123)

Fernhaven

Thames House

Creative Support

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 30 Newland Street 30 Newland Street Crumpsall Manchester M8 5RY Lead Inspector Steve O`Connor Unannounced Inspection 15th May 2008 12:00p 30 Newland Street DS0000021707.V363434.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 30 Newland Street DS0000021707.V363434.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. 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 30 Newland Street Address 30 Newland Street Crumpsall Manchester M8 5RY 0161 740 9397 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) Southfields Care Homes Limited T/A The Regard Partnership Limited Zoe Anne McCall Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th November 2007 Brief Description of the Service: The home is a terraced house situated in the Crumpsall area of Manchester with easy access to local facilities e.g. shops, services, places of worship, pubs and local transport. The home provides accommodation for up to 3 persons with mental health problems. Fees are negotiated on an individual basis with purchasing authorities. 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection report is based on information and evidence we (the commission) gathered since the agency last had a key inspection in May 2007. Additional information, which has been taken into account, included incidents notified to the commission by the agency and information provided by other agencies. Before visiting the home, we asked the agency to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This helped us to determine if the management of the home viewed the service they provide the same way that we see the service. Since the last random inspection the two people who lived at the home had moved on to less supportive accommodation. The Regard Partnership Ltd (Regard), who own and manage the service, had planned to refurbish the house and not accept any new referrals until that was complete. Due to refurbishment plans of other care homes owned and managed by Regard three people from another care home needed to move into 30 Newland Street on a temporary basis. This arrangement had been agreed with the purchasing authorities. At the time of the key inspection those three people were still waiting to return to their own residence but unfortunately surveys had not been sent to them or the staff team supporting them. During the inspection site visit time was spent talking to people, to the area manager, manager, deputy manager and staff. Documents and files relating to people and how the agency was run were also seen. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the agency and to decide how much work we need to do with then in the future. 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: No matter where people live and are supported, staff must have the relevant knowledge and skills to know how to respond to people in that environment and to minimise the risk situations and hazards that may cause them harm. Risk assessment and staff guidance must be relevant to the environment they work in and staff must be given the opportunity and time to be able to read and understand all the relevant information needed to keep people safe before they work with them. 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 7 People were supported to take the medication they need to keep them well. This includes medication prescribed ‘as required’ (PRN). Not all the medication prescribed as PRN had clear administering guidance for staff to follow to make sure that medication was given safely. Regard had introduced a new recording system for managing people’s personal finances. On the whole this was a detailed system with people and staff given clear guidance on how it all works. However, the procedures did not contain any clear and specific auditing and monitoring systems for staff and management to follow to check that the recording and cash balances were accurate. The use of 30 Newland Street as temporary accommodation for people to use whilst their home was being refurbished had delayed its own planned refurbishment. To make sure that the refurbishment work continues another audit of the building and back yard must be undertaken to clearly identify the areas that need refurbishment, the actions to be taken and the time scales they will be completed in. 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. 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 8 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 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s needs had been assessed and were known by the service before they came to live at the home. EVIDENCE: At the time of the visit three people had temporarily moved into 30 Newland Street from another care home, owned and managed by Regard, whilst it was being refurbished. The people were not new referrals and their pre-admission assessments had taken place when they first moved into their original home. Care plans, risk assessments and other relevant information had been taken with them to the home so that they were available for all staff to access. 30 Newland Street DS0000021707.V363434.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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s general needs and basic support had been identified through their care plan. People were supported to make decisions and choices unless agreed through the care plan. Risk and restrictions affecting people’s health and wellbeing were not fully assessed or known by the staff team at the home. EVIDENCE: People’s care plans (called Action Plans) set out individual goals/needs and the support provided by the staff to meet those needs. Care plan goals were being evaluated and reviewed and changes made on an ongoing basis. Whilst the care plans did contain a reasonable amount of information they still did not fully reflect how people were supported and the individual ways that they were helped and encouraged. It is recommended that the ‘person centred’ approach to recording care plans be further developed and used to ensure that people are supported and helped in the way that they want. 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 11 Samples of risk assessments were seen and found that they were being reviewed every three months to make sure that they were still relevant in relation to people’s use of medication, risk of self-harm, mobility, finances, the community, moving and handling needs and other specific identified risks in relation to people’s health and wellbeing. A recent incident involving a person had resulted in a risk assessment and guidance being developed. The assessment and guidance related to the home where they live and not 30 Newland Street. Risk assessments and guidance must be relevant and reviewed when there are major changes in people’s lives and environments. The written risk assessments and guidance to staff on how to manage and minimise those hazards varied in quality and detail of information with some very person centred information and other examples where the guidance was vague. People had been informed and consulted about the temporary accommodation plans before they came to stay at 30 Newland Street. Two people spoken to were not totally happy about the move but understood why it happened. Any restrictions of choice placed on people was only done so as a result of a risk assessment and identified hazards to people’s health, safety and wellbeing. 30 Newland Street DS0000021707.V363434.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): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People enjoy the meals that they choose and have developed their own daily routines and habits. EVIDENCE: Whilst people stay at 30 Newland Street they are being supported by their regular staff and management team. One person is independent in the community and attends a therapeutic work based service during the week. They also visit a friend who lives locally and a family member visits on a regular basis. The deputy manager stated that it was not safe for this person to return home to a house with no staff support. Therefore, as one member of staff was on duty through the day and night it meant that they could not support either of the other two people out into the community whether they wanted to or not. 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 13 Where people normally live there were more people and so more staff on duty and so more opportunities for community-based activities are available for people to participate in. The three people have been living in some form of care environment for many years and have developed their own routines and activities that they want to do at home and do not participate in any domestic activities in the house. The deputy manager did state that they all go shopping with staff to pick the foods and meals that they enjoy themselves. People’s dietary needs, likes and dislikes are taken into account in the meals provided. People were encouraged to maintain a healthy diet and offered choices of meals. Foods stores appeared sufficient with fresh vegetables and fruit available. 30 Newland Street DS0000021707.V363434.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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s personal care and general health needs were being supported. The medication administration system used to manage people’s medication was not as robust as it should be and so placed people at risk. EVIDENCE: People’s personal care needs were identified through the care planning process. The support that staff provide was recorded in terms of prompting, encouragement and the hands-on tasks that are needed. People were encouraged and supported to maintain their general and mental health through accessing general and specialist healthcare services when required. People under the Care Programme Approach (CPA) system had the support of local mental health services. Several examples were seen where people had been helped to access specialist health services and the staff team worked alongside the health service to support people’s changing health needs. 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 15 Before the move to temporary accommodation at 30 Newland Street a serious incident had occurred that related to a person’s access to medication. Risk assessments and guidance had been developed in response to the incident to minimize the likelihood of it happening again and a number of staff had signed the guidance to show that they had read them. It has already been raised in the Individual Needs and Choices section that this risk assessment had not been reviewed and updated in relation to the new environment where the person and staff team found themselves. It was also found that the staff member on duty had not had the opportunity to read the risk assessments and guidance relating to the incident. To make sure that people are supported to keep as safe as possible all staff must be fully aware of, understand and be competent in all written risk assessments and guidance. Medication administration records were all being signed correctly to show administering had occurred. The record of deliveries of medication was being maintained and the deputy manager stated that a physical count and audit of all medication was carried out once a month. However, an audit had not yet been carried out during the time that people had stayed at 30 Newland Street. It is recommended that a physical count and audit is carried out whilst people live at 30 Newland Street. Several people take medication as required (PRN) to help them keep well and healthy. Examples were seen of clear guidance in how PRN should be administered safely. However, it was found that some PRN guidance was out of date, as the person did not use that medication anymore, and there was no PRN guidance for a person’s prescribed painkiller. It was also found that PRN medication was being recorded on the medication administration record sheets without the exact time of administering but was also recorded separately with the correct time. To make sure that people receive the medication they need at the time they need it clear and detailed PRN administering guidance must be developed and understood by the staff team. Recording of the administering of PRN medication must be accurate. 30 Newland Street DS0000021707.V363434.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team followed the practices required to respond to people’s concerns and safety and to try to minimise the risk of abuse. The procedures for managing people’s personal finances did not reflect the safe working practices employed by staff to make sure that finances were correct. EVIDENCE: People had been provided with an ‘easy read’ guide to making a complaint that was clear and included the contact details of the CSCI. A log was maintained of all the formal and informal complaints and concerns received. If a person raises a concern that needs some form of action to resolve, then this would be recorded. A clear adult protection policy and procedure was in place and the staff team and management had access to local adult protection procedures and guidance. The staff spoken to and the deputy manager were all aware of the procedures to take if they have concerns regarding adult protection. The Regard Partnership Ltd had introduced a new system for the recording and management of people’s finances. This new system involved each person having a separate record of their income and expenditure, where receipts for spending were maintained and recorded. Monies were kept in sealed bags that required new seals every time they were opened. These seal reference numbers were recorded as well. 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 17 The way that people were helped with their personal monies was set out in a clear ‘easy-read’ document. The guidance for procedures set out what staff had to do and what to record. The guidance was clear and informative and told staff exactly what they needed to do. It was found, however, that the procedures did not contain any guidance that people’s money balances had to be counted to make sure the figures were correct. The only auditing system referred to the Quality Assurance or Area manager carrying out checks but this did not specify any time frames or recording procedures for the audit. Even though the deputy manager stated that staff were carrying out their own checks of people’s monies on a daily basis, this was not being recorded. To make sure that people’s money was safe and that staff recording was correct, the procedures for recording and managing people’s personal monies must contain a clear and thorough auditing and monitoring system. 30 Newland Street DS0000021707.V363434.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises were generally clean but did not provide a homely environment for people to live. EVIDENCE: On the 2nd July 2007 Regard provided us with an action plan for the refurbishment of 30 Newland Street. Due to the previous people moving to more independent living and its use as temporary accommodation the majority of the refurbishment programme has not been completed. The random inspection we carried out in November 2007 found that some improvements had been made to the kitchen units and area. The current visit found that some decoration had been carried out to make the environment a more pleasant place to live. 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 19 However, Regard had previously met with us to confirm their commitment to raising the standards of the environment at 30 Newland Street. To make sure that this work continues another audit of the building and back yard must be undertaken to clearly identify the areas that need refurbishment, the actions to be taken and the time scales they will be completed in. The laundry facilities are located next to the kitchen area and are suitable for people’s needs. 30 Newland Street DS0000021707.V363434.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): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People were supported by a staff team who had accessed a range of training events to develop their skills. Staff required more knowledge of individuals needs to keep them safe. EVIDENCE: At the time of the site visit to 30 Newland Street people were being supported by the same staff team who would normally be supporting them. The registered manager, of that care home, was not available but the deputy and later the area manager were present for the inspection. The staffing levels were based on one staff being available for people throughout the day and night. The issue of staff not having much opportunity to support people in the community has been raised previously in the report. It is recommended that the flexibility and use of staffing be assessed to allow people to access the community at the times that they wish. 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 21 The member of staff on duty was able to describe the Induction programme they had participated in and the different subject areas covered. They had started the NVQ Level 2 qualification and had attended Protection of Vulnerable Adults and Medication training. The issue of the need for all the staff team to be fully aware of key risk assessments and practice guidance has been raised in the Personal and Healthcare section of the report and raises the issue of the service providing staff with the knowledge and skills they need to keep people safe. The training records for the remainder of the staff team were not being stored at the home during the temporary stay. The Regard Partnership Ltd had worked with the CSCI and agreed that the company’s records relating to staff recruitment and employment checks would be inspected at their head office by a Provider Relationship Manager (PRM), a senior manager within the CSCI. They last audited the staff files in February 2007 and found, on the whole, that the correct checks were being made to make sure that staff who work with vulnerable people were safe to do so. 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management team and operational systems were in place to seek people’s views of the service and to maintain their health and safety. EVIDENCE: The registered manager of 30 Newland Street has several years management experience working with people who present a challenge to the service and had completed her Registered Managers Award in 2003. At the time of the site visit they had no direct management input into the way the service was managed. 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 23 The people staying temporarily at 30 Newland Street were from another care home, within Regard, and the staff and management team from their permanent address were continuing to support them. At the time of the site visit the registered manager for people’s permanent home was not available. The deputy manager was available and split their time between the different care homes that people were temporarily staying. In addition, the area manager was available to offer management support if required. Regard had an established system of quality assurance undertaken by the company’s Quality Manager. This included regular regulation 26 visits to the home to assess how the service was meeting the National Minimum Standards. Due to the temporary nature of the stay at 30 Newland Street these inspection visits had not yet taken place. It is recommended that if the proposed length of stay at 30 Newland Street extends beyond the current arrangements then the formal quality assurance procedures should be applied. Health and safety checks in relation to fire, equipment and services were being maintained. 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 3 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 YA9 Regulation 13 (4) (b)(c) 13(2) Timescale for action Risk assessments and guidance 30/06/08 must be relevant and reviewed when there are major changes in people’s lives and environments. To make sure that people are 30/06/08 supported to be as safe as possible all staff must be fully aware of, understand and be competent in written risk assessments and guidance relating to medication. To make sure that people receive the medication they need at the time they need it clear and detailed PRN administering guidance must be developed and understood by the staff team. Records of PRN administering must be accurate. To make sure that people’s 30/06/08 money was safe and that staff recording was correct the procedures for recording and managing people’s personal monies must contain a clear and thorough auditing and monitoring system. Requirement 2 YA20 3 YA23 13(6) 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 26 4 YA24 23(2) 5 YA39 24 (2) To make sure that the 30/06/08 refurbishment work continues an audit of the building and back yard must be undertaken to clearly identify the areas that need refurbishment, the actions to be taken and the time scales they will be completed in. Copies of the Regulation 26 visits 30/06/08 must be submitted to the CSCI to show that the home is addressing the issues raised in this inspection report. 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 YA6 Good Practice Recommendations It is recommended that the home develop and implement a more person centred planning approach to how people identify their own needs, goals and the help they need to achieve them. Also that the home evidence that people are fully involved in the review of their individual care plan. It is recommended that a physical count and audit was carried out whilst people live at 30 Newland Street. It is recommended that the flexibility and use of staffing be assessed to allow people to access the community at the times that they wish. It is recommended that if the proposed length of stay at 30 Newland Street extends beyond the current arrangements then the formal quality assurance procedures should be applied. 2 3 4 YA20 YA33 YA39 30 Newland Street DS0000021707.V363434.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 30 Newland Street DS0000021707.V363434.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. 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