Inspection on 24/08/07 for 44 Castle Road

This inspection was carried out on 24th August 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

44 Castle Road 07/07/09

44 Castle Road 01/11/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Castle Road, 44 44 Castle Road Cookley Nr Kidderminster Worcestershire DY10 3TF Lead Inspector Dianne Thompson Key Unannounced Inspection 24th August 2007 10:00 Castle Road, 44 DS0000066852.V346032.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 Castle Road, 44 DS0000066852.V346032.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. Castle Road, 44 DS0000066852.V346032.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Castle Road, 44 Address 44 Castle Road Cookley Nr Kidderminster Worcestershire DY10 3TF 01562 852405 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) www.dimensions-uk.org Dimensions (UK) Ltd vacant post Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Castle Road, 44 DS0000066852.V346032.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within 3 months of the date of registration Dimensions (UK) Ltd will finalise lease, management and care arrangements with the County Council as referred to in the ‘Statement of Understanding’ dated 28th March 2006 and provide the Commission with the copies. 1st November 2006 Date of last inspection Brief Description of the Service: Castle Road is a traditional two storey detached house in a residential street. The bedrooms are individually decorated and furnished. There is a shared lounge, dining area and kitchen. Local shops and access to public transport are nearby, whilst the home has its own vehicle for people who use the service to use locally. The home aims to provide a domestic environment promoting independence and dignity. People who use the service receive care and support to live as ordinary a life as possible in the community. This involves staff teaching skills and creating opportunities on behalf of individual people. Individuals are encouraged to participate in the running of the home and share in general household activities within their capabilities. Dimensions (UK) Ltd is now the care provider for the service, having registered with the Commission for Social Care Inspection on 1st April 2006. The fees range from £62.35 per week. Charges that are additional to the fee include: Personal toiletries, clothing and electrical items (TV and music centre). Activities not covered by the allowance made by the provider or in the funding authority contract include holidays, major extra outings and hairdressing. Castle Road, 44 DS0000066852.V346032.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit to see what the home was like to live in for the people who live there. The inspector talked to some of the people who live at Castle Road and some of the staff working there. We looked at some of the policies and procedures in the office. Policies are rules about how to do things. We spent some time looking at records in the office. We sent out surveys to get views about the service from other people. The manager completed an Annual Quality Assurance Assessment (AQAA) and sent this to the Commission for Social Care Inspection (CSCI). Some of the information provided in the AQAA will be included in this report. What the service does well: What has improved since the last inspection? Person centred care plans are now being completed for everyone who lives at Castle Road. Things are written down so staff can follow this where there are any health worries or concerns. Dimensions checks on the quality of the service being provided at Castle Road. They ask many people for their views about the home. A report is then written and plans are then made to make any changes that are needed. Castle Road, 44 DS0000066852.V346032.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. Castle Road, 44 DS0000066852.V346032.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 Castle Road, 44 DS0000066852.V346032.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): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A range of information about the home is made available so that people can make a choice about living at the home. Assessments are completed before people move into Castle Road, to make sure their individual needs can be met. EVIDENCE: There have been no new admissions to the home, but there are policies and procedures in place should there be a vacancy. A brochure about the home, a Statement of Purpose and Service User guide is available. This information has been compiled in different formats such as pictures and symbols, large print and audio that makes it is easier for people to understand. The manager provided an example of information in the alternative formats that is to be printed and supplied to everyone when they have been printed. Surveys confirmed that information about the home is shared, and that they are kept up to date with important issues. Full assessments were completed for everyone before they moved into Castle Road. A care plan is written based Castle Road, 44 DS0000066852.V346032.R01.S.doc Version 5.2 Page 9 on the information from the assessments, when a person comes to live at Castle Road. Castle Road, 44 DS0000066852.V346032.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, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The staff at Castle Road are meeting individual needs. Care plans are kept up to date and reviewed regularly to make sure that staff have all the information they need to provide consistent support. Risk assessments show how risks are to be reduced and the ways that independence is promoted and maintained. EVIDENCE: Care plans for two people were examined. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health needs and disability requires greater input and support from all staff within the home. Dimensions are implementing a person centred approach (PCP) to all their services and their recording system emphasises this approach. Information provided in Care Plans covered areas such as likes and dislikes, diet, Castle Road, 44 DS0000066852.V346032.R01.S.doc Version 5.2 Page 11 communication and personal care. A pictorial assessment includes information that is accessible to everyone, with information relating to sleeping and resting times that are needed, with guidelines in place for eating and drinking. There is evidence to show that personal support plans are reviewed regularly and that follow up dates are arranged in advance. A statement of participation in care plan reviews is recorded that provides an explanation of how much participation each individual is able to cope with during these meetings. The staff team are able to use other less formal ways of finding out what people like or dislike, and what they want to do or not do. Each person is allocated a key worker to oversee his or her care. There is evidence of key worker support and encouragement to make sure that people who use the service are fully involved in the reviews of their care plans. Staff are fully aware of the plans and follow them to guide their practice. Family surveys confirmed that care given is what they expected or agreed with the service. Staff have had some training in completing Path maps, having been on an away day to complete the Path map for the service. Using the knowledge and experience gained, staff are more confident to support people who use the service to complete their Path maps. Risk assessments are completed to keep people safe, with suitable guidelines for assistance as necessary. The risk assessments seen have been reviewed regularly and explore ways to make sure that people are able to be as independent as possible. Care needs to be taken that the frequency of the review is as stated on the risk assessment, for example one risk assessment states that reviews should be held every three months. Castle Road, 44 DS0000066852.V346032.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, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People receive help and encouragement to lead active and interesting lives. Everyone is encouraged and supported to maintain links with their families and to develop friendships. Dietary needs are generally well catered for with a varied and healthy menu provided. EVIDENCE: At the time of the inspection visit everyone was preparing to go out for a day trip. The service has an activities co-ordinator and regular activities are planned. The manager said the activity coordinator is ‘to map the local area for more community participation for the people we support’. A range of activities is promoted for people who use the service, both in-house and within the local community. These activities include going to the Monday Club every Castle Road, 44 DS0000066852.V346032.R01.S.doc Version 5.2 Page 13 two weeks, going for walks, swimming, food shopping, listening to music or talking books and sitting in the garden during the warmer weather. Records of all activities planned and carried out are available to illustrate the lifestyles for people who use the service. Opportunities are discussed regularly with people who use the service through their weekly meetings. Planning activities, menus, and any other issues within the home are discussed. There are plans to participate in the Dimensions Day that is being arranged. This will take place on the 3rd September at the Bromsgrove Hotel. There will be a presentation of a ‘Year in Pictures’. At lunch time there is to be a release of balloons to mark the day and following lunch there is to be a talent show. Holidays are regularly planned. As part of the development of the service the manager states in the AQAA that they will ‘offer the chance to try new experiences in regards to activities, holidays’. ‘Holidays and day trips are more individualised’. Evidence shows that regular contact with friends and family is supported. Survey responses show that families visit their relative at the home on a regular basis. Menus are planned during weekly meetings when people make their choices for the coming week. Records show that meals have become more varied and nutritional, and alternative meals are recorded where these have been chosen. In the AQAA the manager says that there is ‘ more flexibility with regard to meals, when and what to eat, where to eat’. Castle Road, 44 DS0000066852.V346032.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Details of people’s personal and healthcare needs are clearly identified in care plans and health action plans. This detail informs staff how care is preferred and makes sure that support is provided in a consistent way. Dimensions’ has a medication policy and procedure for staff to follow to ensure that all medication is administered and stored safely for the protection of everyone who uses the service and staff, although not all staff are trained in the administration of medication. EVIDENCE: Each person has a health action plan included with their care plan which sets out how their health needs are to be met. Regular checks and monitoring is being recorded in health action plans. In the AQAA the manager states that ‘Individual health action plans document changes to peoples health, or when people have been supported to attend healthcare appointments’. Castle Road, 44 DS0000066852.V346032.R01.S.doc Version 5.2 Page 15 People have good access to medical support through their GP, psychologist, opticians, speech and language therapists, dentist, chiropodist, and the community learning disability team. People are offered annual health checks through the community nurse. Some people pay for regular reflexology treatment that is provided in the privacy of their own rooms. Staff were observed providing support for people in a respectful way, making sure that each persons’ dignity and self esteem was important. Although people who were at home at the start of the inspection visit were unable to communicate their views of the home, they appeared to be comfortable and at ease in their surroundings. Medication is well managed by the staff at Castle Road. Medication is stored securely and given to people at the right time and full records are kept which show this. A medication policy and procedure is in place and provide guidelines to follow should any medication error occur. Additionally, procedures advise that errors are to be reported to the CSCI. In the AQAA the manager states that ‘plans for the coming year include a change to the medication record system currently used and work towards people keeping their medication in their own rooms’. Staff training records show that medication training is not up to date for all staff and must be rectified as soon as possible. Castle Road, 44 DS0000066852.V346032.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): 23, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service have access to easy to understand information about how to complain and staff support people to express their views and any concerns they may have. There are suitable procedures in place for the management of complaints. Staff training and monitoring makes sure that everyone who uses the service is protected from abuse. EVIDENCE: There are suitable procedures in place at Castle Road to respond to any allegations of abuse and for managing any complaints made about the service provided. A copy of the local procedures is also available. The complaints procedure is available in different formats so that people are able to access the information. Staff support people who live at Castle Road should they wish to make a complaint. Survey responses show that people are aware of the complaints procedure and that no complaints have been made. The CSCI has not received any complaints about the home since the previous inspection. One compliment has been recorded from a relative that refers to ‘how happy and how well‘ their relative looks. People are supported to make complaints and include making families and friends aware of the complaints procedure. Staff receive training in abuse awareness, and this training is part of induction training for new staff. This is Castle Road, 44 DS0000066852.V346032.R01.S.doc Version 5.2 Page 17 confirmed in the AQAA where the manager states that ‘Staff are trained in ‘our approach’ around person centred awareness, and communication to consider alternative methods and techniques for people we support’. There are suitable finance procedures in place. Everyone who uses the service has their own safe in their bedroom for keeping their money secure. The manager makes regular checks, and the provider audits all finances on a monthly basis. Risk assessments are completed to help people in the management of their money. Castle Road, 44 DS0000066852.V346032.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, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at Castle Road enjoy a comfortable and homely living environment. The home is spacious and is kept clean and well maintained. EVIDENCE: Castle Road is a traditional two storey detached house in a residential street. The bedrooms are individually decorated and furnished. There is a shared lounge, dining area and kitchen. Local shops and access to public transport are nearby, whilst the home has its own vehicle for people to use locally. The home has an extension that incorporates a ground floor bedroom with ensuite facilities. There are handrails around the home to help people with a visual impairment. The home is being redecorated. People who use the service choose their colour schemes for their rooms and the communal areas of the home. Plans for further improvement during the coming year include the installation of a Castle Road, 44 DS0000066852.V346032.R01.S.doc Version 5.2 Page 19 new shower to the upstairs bathroom, and a new disabled access to the side of the house. Specialist equipment is available as required. A pressure mattress and bedside bumpers have been obtained where the need has been identified. The flooring to the upstairs bathroom is to be repaired and it is hoped to install a sensory area and some seating into the garden to improve access to the garden during the warmer weather. The office has been moved downstairs and this has improved safety through access to staff at all times. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. Communal bathrooms have paper towels and liquid soap available. All cleaning materials are stored in locked cupboards in the laundry room. Staff were seen wearing suitable protective clothing for the work they were doing. Castle Road, 44 DS0000066852.V346032.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, 34, 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty with the right skills and knowledge to meet the needs of people who live at Castle Road. Staff are well supported and work to provide consistent and good quality care. Staff are given training to help them meet the needs of people who use the service. Dimensions’ recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to ensure the safety of everyone living at Castle Road. EVIDENCE: Castle Road service has a committed staff team although they have been short staffed. People on annual leave and long-term sick leave have compounded this. The service has however employed two new members of staff. The manager said the staff team offers a good skill mix including one male staff member who will assist with male residents. Staff need to develop their team working relationships to reflect the skills within the team and the needs of people who use the service. The manager plans to incorporate some team Castle Road, 44 DS0000066852.V346032.R01.S.doc Version 5.2 Page 21 building sessions into the training programme. A training plan is being completed to make sure everyone’s training is up to date. Although Dimensions provide regular staff training there are some gaps in the training records for staff working at Castle Road. Recent training has included epilepsy, communication and manual handling. All staff should complete medication training. At the time of the inspection only three staff out of a team of nine working at Castle Road are qualified to NVQ level with no one currently working to complete this. NVQ training needs to be undertaken. Dimensions recruitment policy and procedures ensure that everyone completes an appropriate application form and that required references are obtained including one from their most recent employer. Appropriate criminal records and other checks are undertaken before their appointment is confirmed. All staff are required to work a probationary period at the home. Recruitment records were seen for two new members of staff. The records are well maintained and contained all the required information and safety checks. All newly employed staff complete an Induction Course. The Induction process also includes new staff being supported by senior staff to familiarise themselves with the home, people who use the service and safety matters. A new member of staff spoken to said that he enjoys the job and has brought his previous knowledge and skills to the service. He and the manager confirmed that all recruitment procedures had been followed. Castle Road, 44 DS0000066852.V346032.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, 42 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 managed and staff receive the leadership and support they need, although the manager has not yet registered with the CSCI. Dimensions monitor the home in various ways to make sure that the health and welfare of people using the service is protected. EVIDENCE: The manager of the home is Claire Taylor. Claire is a registered learning disability nurse and was previously the registered manager for another Dimensions home. Claire has many years experience working with people with learning disabilities and regularly completes training relevant to her position. She is involved in regional advisory forums, staff conferences and PATH meetings. Claire is completing her Registered Managers Award. The service Castle Road, 44 DS0000066852.V346032.R01.S.doc Version 5.2 Page 23 benefits from a permanent manager, although an application for registration with the CSCI must be completed. The Annual Quality Assurance Assessment (AQAA) was completed by Claire and sent to the CSCI within the required timescales. The AQAA says that the ‘Home has coped with the change of provider and style of service, new working practice methods without disrupting the day to day activities and lifestyles of the people being supported’. Castle Road has become more person centred in their approach and this is evident from the improvement in the recording systems, the methods used to make sure that everyone who lives at Castle Road is fully involved in the running of the home and the way they live their life. Staff confirmed that the manager is approachable and supportive. Additionally, Dimensions support the management of the home in various ways. For example there are training and human resource staff who are able to provide advice and support as required. The provider’s monthly visits are one of the ways that Dimensions monitors the service and how the home is being run. These visits include interviews with staff and people who use the service. An audit of relevant parts of the service including records, environment, complaints received, finance and safety is completed. Any actions that may be needed to address shortfalls are specified. The resulting reports are also part of the home’s quality assurance and monitoring system and are intended to form an annual development plan for the service. This report will include views on the service from people who use the service, stakeholders and interested parties. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Generic risk assessments are in place. Regular audits for food hygiene, management, and health and safety are completed. Castle Road, 44 DS0000066852.V346032.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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 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 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Castle Road, 44 DS0000066852.V346032.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 YA20 Regulation 13 (2) Requirement Arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home must be made. Specifically this means that all staff must be trained in the safe administration of medication. People working at the home must be suitably qualified, competent and experienced. Specifically this means that NVQ training needs to be undertaken to make sure that 50 of the staff team are suitably qualified. The manager must complete an application for registration with the CSCI. Timescale for action 22/12/07 2. YA32 18 (a) 22/12/07 3. YA37 9 (1) 22/11/07 Castle Road, 44 DS0000066852.V346032.R01.S.doc Version 5.2 Page 26 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 YA9 Good Practice Recommendations The frequency of reviews of risk assessments should take place as stated on risk assessments. One risk assessment states that reviews should be held every three months. Castle Road, 44 DS0000066852.V346032.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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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