Inspection on 21/03/07 for 40 School Road

This inspection was carried out on 21st 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

40 School Road 22/02/06

40 School Road 27/09/05

40 School Road 03/02/05

40 School Road 22/07/04

40 School Road 24/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 40 School Road Brislington Bristol BS4 4NN Lead Inspector Sandra Jones Key Unannounced Inspection 21st March 2007 09:30 40 School Road DS0000053613.V332933.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 40 School Road DS0000053613.V332933.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. 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 40 School Road Address Brislington Bristol BS4 4NN 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) 0117 3772543 Bristol City Council Mrs Sheena Huggins Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Respite care is for no longer than 6 weeks. Occupancy for over 6 weeks requires a formal application for variation. Date of last inspection 22nd February 2006 Brief Description of the Service: 40 School Road is operated by Bristol City Council and is registered by The Commission for Social Care Inspection to provide short-term accommodation to seven adults (male and female) with a learning disability between the age of 18 years and 64 years. A condition of the registration is that accommodation is not offered for a period longer than six weeks. The property is detached and is set in its own grounds. There are disabled facilities on the ground floor. There is also one double room, which would be suitable for a couple. The home is arranged over two floors, but all communal areas are on the ground floor. There is no lift facility. 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted unannounced in March 2007 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises conducted and feedback sought from individuals on respite care and staff. Four completed “Have your say” surveys were received at the Commission from people who use the service. Feedback from relatives and Health and Social Care Professionals was sought through comment cards. Five comment cards were received from families and friends and two from community nurses. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the pre-inspection questionnaire and notified incidences in the home, (Regulation 37’s). What the service does well: What has improved since the last inspection? The manager is in the process of conducting a service review. 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 6 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. 40 School Road DS0000053613.V332933.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 40 School Road DS0000053613.V332933.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is in breech of its condition of registration by accommodating one individual over six weeks without making a formal application to the Commission. EVIDENCE: The admission process is clearly described within the Statement of Purpose and stipulates that admissions are based on full social workers assessments. Within the policy, the arrangements for introductory visits are also included. The member of staff in charge described the arrangements in place for booking short stays. People that use the service and relatives receive a booking form to use within a three-month period. The home has one emergency bed and an emergency admission protocol is in place. The protocol is not specific about the arrangements to fully assess and relocate individuals placed at the home as emergency admissions. 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 9 Four completed “Have your Say” surveys from people that use the service were received which state that before visits take place, information about the home is provided. One person at the home during the visit confirmed that a copy of the home’s Service User Guide and Complaints procedure was provided. One person has been at the home since 28/12/06 and while termination notice was given on 12/02/07 this person continues to be accommodated. There is a condition of registration, which stipulates that occupancy for over 6 weeks requires a formal application for variation. This is a breech of the conditions of registration. Although there is a care plan in place for this person, this is not devised from a full needs assessment. The home’s Statement of Purpose does not specify the time limit for which people receiving respite care will be accommodated (as agreed by CSCI). 40 School Road DS0000053613.V332933.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The care planning system must be more effective so that people who use the service can benefit from a consistent service. People that without communicate needs can expect to be involved in making decisions. Risk assessments are in place for activities that involve an element of risk. EVIDENCE: The member of staff in charge at the time of the site visit stated that pen pictures and care plans are drawn up from the information gathered through discussions with the person, the social workers profile and assessment of needs. A full care plans follows, which is then reviewed at the time of each admission. Overall the needs of the people that use the service are reviewed as soon as possible. 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 11 The case records of six individuals accommodated at the home were examined during the site visit and only four were up to date. While it is acknowledged that these admissions are recent, the home was aware of the pending admissions. The member of staff in charge confirmed that a keyworker system is in operation and it is the manager that appoints the keyworker. It was further explained that the role mainly entails updating care plans. On re-admission care plans are updated and signed by the Keyworker. However, people that use the service or representatives do not sign the updated care plans. Home’s care plans detail the individuals past history, area of need with an account of the individuals likes, dislikes and preferred routines. An action plan is then developed which details the identified need, actions required and the person responsible for undertaking the task. Care plans generally focus on daily living, personal care and medical needs. The emotional, intellectual and social care needs of the individual are not currently included in the care plan. The person at the home during the site visit was consulted about the care planning process. This individual stated that discussions about areas of need take place with the staff. Running reports are compiled by the staff and describe the individuals daily activities, outcome of visits and personal care provided. At the time of the site visit one person with communication needs was accommodated. Care plans are not detailed about the means used by this individual to communicate and make decisions. Three “Have your Say” surveys from people that use the service indicate that they always make decisions about what they do each day. One person stated that they sometimes make decisions about what to do each day. Risk assessments are in place for activities that may involve an element of risk which generally focus on safety and manual handling. The information held within the assessment is not clear about the options available to reduce the level of risk. The home maintains an accident file and since the last inspection there were no recorded accidents. 40 School Road DS0000053613.V332933.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There are good support systems in place for people who use the service to continue with pre-arranged activities during their respite care. Members of staff support the people on respite care to access community facilities. Systems are in place that ensures the people who use the service are respected as individuals. EVIDENCE: It was understood from the person in charge that people on respite are able to continue with community-based activity. Where there is no pre arranged day care activities for individuals on respite care, activities are organised on a daily basis. It is acknowledged that information about the individual daily activities is recorded in their pen portraits, the care plans must be more specific about wishes and goals for people that are on respite care for over two weeks. 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 13 The deputy stated that people at the home during the day generally go on pick-up and drop off to the day centre and watch television. “Have your say” surveys from people that use the service indicate that they can do what they want to do throughout the day. One person stated that when at the home during the day, watching television and videos, “doing word search puzzles” brought from home are the activities undertaken. It was further stated that sometimes at weekends outings are organised by the staff at the home. The resident at the home during the inspection stated that there were no structured day time activities arranged watching the television and videos were they way day was spent at the home. The deputy manager stated that the people currently using the service require the assistance of the staff outside the home. There is a home’s minibus and generally, it is used to take individuals on respite to and from their set programme of community-based activities. Contributions towards the running cost of the minibus are made through the weekly charges. The arrangements in place for visiting the home are included in the Statement of Purpose. A visitor’s book is in place and the name and nature of the visits are recorded. It was understood from the deputy manager that one person has visitors and carers usually ring the home, as one of the home’s aims is to provide respite for carers. It was noted within the case file of one individual on respite care, that restrictions are to be imposed on a relative about information to be provided. A risk assessment must be completed to demonstrate that this action is proportionate to the level of risk. The views of the relatives involved with the people that use the service was sought. Five completed comment cards were received and indicated that staff welcome visitors to the home, visits can take place in private and they are kept informed about important matters that affect their relative. Two people made additional comments about the staff’s abilities and the standards of care provided. The deputy manager was consulted about the arrangements in place for respecting the rights of people. It was stated that the Privacy and Dignity policy and Local Authority Code of Practice set the approach used to respect the rights of the people that use the service. For example, staff knock and wait for an invitation to enter and medical care is conducted in private and environmentally bedrooms are singes and lockable. Information about rules and expectation are included in the Service User Guide and the Terms and Conditions of residency state that staff will agree a time to access bedrooms for cleaning. Feedback about household chores was then sought from the deputy manager and individuals at the home. 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 14 The individual at the home stated that there were no expectations that people on respite care undertake household chores. It was further stated that there are no structured rules for rising or retiring. The deputy comments also confirmed the findings. The deputy manager stated that menus are devised by catering staff and the manager. The person at the home made favourable comments about the food served at the home. There is a wide range of fresh vegetables, fruit, canned and dried foods that indicate individuals on respite care have a varied and nutritious diet. A record of food served with alternatives to the menus is not currently maintained at the home. 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People that use the service can expect sensitive and prompt support for their personal and health care needs from a skilled staff team. Medication systems are safe. EVIDENCE: The person at the home was consulted about manner in which staff provide personal care. The comments made by this individual clearly indicate that staff use a sensitive approach to people that require personal care. Care plans in place describe the person’s needs with personal care. It was noted that one person may require assistance with getting up and risk assessments are in place. Risk assessments for bedsides and manual handling techniques are not clear about the level of risk or the specific about the support needed. Risk assessments are not currently reviewed on each visit. The deputy manager stated that the downstairs bedroom is equipped for people that have mobility impairments. 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 16 Feedback from Health and Social Care Professionals was sought through comment cards and two were received from Community Nurses. Affirmative answers were made about staff’s ability to communicate clearly with external agencies. Additional positive comments were made about the staff’s abilities to include medical advise into care plans. The manager stated that the home is registered with a local GP for people using the service who are outside their GP’s catchment area. It was understood from the deputy manager that where appointments are arranged to occur during respite stays, the home would endeavour to support the person to keep the appointment. It is the policy of the home to only accept medication that is clearly labelled by the pharmacist for staff to administer. There is a system in place for recording medications received and returned to the person on respite care. It was understood from the manager that to maintain safe practices of administration, staff that administer medication attend medication administration training. The records of administration and medications held at the home crossreferenced. Records of administration also indicated that staff sign the records immediately after administering medications. Individual medication profiles that list prescribed medication and known allergies are in place. However, the purpose of the medication and known side effects are not included in the profiles. 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 17 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. Residents can expect their concerns to be listened to and to be protected from abuse. EVIDENCE: The home’s Complaints procedure is written in a simple format with pictures to ensure that the people for whom its intended can understand it. The person at the home confirmed that a copy of the Complaints procedure is provided during the admission process. It was noted that the name of the Commission, the address and telephone number is not incorporated into the procedure. Four “Have your Say” surveys from people that use the service indicated that they know who to speak to if they are not happy. Three indicated that they know how to make a complaint. A record of complaints received at the home is maintained which lists the name of the complainant, the nature of the complaint and the actions to be taken. The level of satisfaction is not currently included within the record of complaints. The Local Authority “No Secrets” policy is available at the home and staff have attended Safeguarding Adults training. 40 School Road DS0000053613.V332933.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well maintained so residents benefit from living in a comfortable and clean environment. EVIDENCE: School Road is a detached property set in its own grounds. It has the appearance of a large domestic dwelling, which blends well with its immediate environment. Accommodation is arranged over two floors, with shared space on the ground floor and bedrooms on both floors. In general, the environment is well maintained and suited to the people that use the service. The property is decorated and furnished to a standard that creates a comfortable homely atmosphere. 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 19 Bedrooms have furniture and fittings that are suitable to the needs of the people that use the service. The bedrooms of the people that are currently on respite care contained personal belongings to enhance their personal space. The bedroom on the ground floor is for people with mobility impairments. It contains low level switches, adapted en-suite facilities, an emergency call system and furniture that promote independence. The person at the home during the inspection stated that personal items can be taken into the home. Three people indicated through the “Have your Say” surveys that the home was always clean. One person stated that the home is was usually kept clean and fresh The communal lounge/ dining area on the ground floor is very comfortable and homely. There is sufficient seating in the lounge and dining room for the number of people that can be accommodated at the home. The conservatory is smaller and provides limited seating. A number of minor repairs were observed during the tour of the premises. The loose cord from the skylight in the upstairs bathroom needs attention as well as the flooring in room 7 and in room 5 a bedside cabinet is needed. The laundry is sited away from the kitchen and for easy cleaning the flooring is vinyl and walls painted. There is an industrial washing machine with sluicing programmes and tumble dryer. 40 School Road DS0000053613.V332933.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): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People that use the service must be supported by staff that are suitable to work with vulnerable adults. EVIDENCE: The personnel files of the five most recently employed staff were examined. Completed application forms and the two written references sought were found within the staff’s files. For one person professional references from the previous employers were sought but character references were accepted. In terms of references, the authenticity of the referees are not always established when standard request for references are used. Notification of Records of Criminal Records Bureau (CRB) checks sent to the home from HR are inconsistent. A CRB check for working at the home was not obtained for one person and for others notification was not specific about the level of clearance. 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 21 It was understood from the manager that new employees must complete the Common Induction and an in-house induction. In-house induction covers familiarization of the building, Health and Safety, care needs of the individuals that use the service, policies and procedures. Learning Disabilities Award Framework (LDAF) training follows on from the induction programme which ensures staff have an insight into the needs of the people that use the service. It was further stated that statutory training is undertaken in blocks and staff must undertake medications, Safeguarding Adults, Minibus and Diabetes training. Members of staff are encouraged to undertake vocational qualifications and currently three staff have completed NVQ level 2, two have NVQ level 3 and the deputy is undertaking NVQ level 4. It was understood that there is no training programme to maintain staff skills with the changing needs of the people that use the service. Members of staff comments indicated a clear understanding of all forms of abuse and the actions that must be taken. Members of staff confirmed that training and vocational qualifications is accessible. Consistency of care is maintained through supervision and team meetings. Three “Have your Say” surveys from people that use the service stated that staff always treat them well and one stated that usually they are treated well by the staff. 40 School Road DS0000053613.V332933.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People that use the service live in a safe environment and to be re-assured that standards will be the subject of ongoing monitoring, staffing issues must be addressed. EVIDENCE: The manager was consulted about meeting the aims and objectives of the home. In terms of the day-to-day management, it was reported that there is sufficient supernumerary time to undertake the responsibilities of the role. It was additionally reported that part of the role is to consistently analyse the provision of the service. 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 23 Members of staff and people that use the service were positive about the style of management. Members of staff stated that the manager has an open approach and suggestions made are always taken seriously. The manager was consulted about existing staff disciplinaries. It was reported that a member of staff was disciplined for medication errors some months ago and the outcome remains pending. The manager was consulted about the Quality Assurance system in place at the home. It was understood that an external advocate is used to seek feedback about the premises, the food and the staffing. Quality Assurance surveys are written in a simple format using pictures to ensure the people for whom it is intended can understand it. There is a business plan in place and relates to the unit review. The records that relate to Health and Safety checks were examined. Fire risk assessments are in place and satisfy the Regulatory Reform (Fire Safety) Order 2005. Other checks undertaken to maintain a safe environment for the people that use the service include annual checks of the heating system and portable equipment. 40 School Road DS0000053613.V332933.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 2 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 x 33 x 34 1 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x LIFESTYLES Standard No Score 11 X 12 2 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 3 x x 3 x 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 25 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 YA2 Regulation 14(2) Requirement All needs assessments must be kept under review and revised at any time following consultation with the service users and or their representative. There must be an up to date assessment in place. This is an on going requirement from the previous inspection conducted on the 25/09/05 & 22/02/06 CRB disclosure checks must be undertaken for each person working at the home. The manager must establish the authenticity of references whenever standard request for references are used The Statement of Purpose must be updated to reflect the time limit for which the home intends to provide respite care. The Commission must be notified of the any allegations of staff’s misconduct. This includes a report of the most recent disciplinary for drug error. Timescale for action 30/06/07 2. 3. YA34 YA34 7,9 &19 Sch.2.2 19 (1) (c) 30/04/07 30/07/07 4 YA1 4(1) (c) Sch1 37 30/07/07 5 YA37 30/04/07 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 26 6 YA7 17 (1) (a) Sch.1.l 7 YA7 17 (1) (a) Sch 3.3q 10 YA9 13.4 (c) To enable people that use the 30/06/07 service to make decisions, the means used to communicate must be incorporated into the care plans of people with communication needs. Where limitations are to be 30/05/07 imposed, a risk assessment must be undertaken to ensure the actions are consistent with the level of risk and the persons wishes Risk assessments for bedsides 30/06/07 and manual handling techniques must be clear about the actions to be taken to reduce the risk for people that use the service. 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 YA20 Good Practice Recommendations Medication profiles should include the purpose of the prescribed medication with its side effects. 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 40 School Road DS0000053613.V332933.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!