Inspection on 18/09/08 for 47-49 All Saints Road

This inspection was carried out on 18th September 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

47-49 All Saints Road 19/03/08

47-49 All Saints Road 01/12/06

47-49 All Saints Road 20/03/06

47-49 All Saints Road 28/07/05

47-49 All Saints Road 11/03/05

47-49 All Saints Road 13/01/05

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

Extracts from inspection reports are licensed from CQC, this page was updated on 04/12/2008.

CARE HOME ADULTS 18-65 All Saints Road, 47-49 47-49 All Saints Road Bromsgrove Worcestershire B61 0AQ Lead Inspector Debra Lewis Key Unannounced Inspection 18th September 2008 12:30 DS0000061835.V372165.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 DS0000061835.V372165.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. DS0000061835.V372165.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service All Saints Road, 47-49 Address 47-49 All Saints Road Bromsgrove Worcestershire B61 0AQ 01527 579520 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) Worcestershire Mental Health Partnership NHS Trust Mrs Amanda Deborah Jeffries Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (2) DS0000061835.V372165.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th March 2008 Brief Description of the Service: 47-49 All Saints Road is a traditional two storey detached house in a residential street within a mile of Bromsgrove town centre. Each person living in the home has their own bedroom, individually decorated and furnished, with 2 shared lounges, a dining area and kitchen. Local shops, public transport, the Mental Health Resource Centre and voluntary sector day centres are nearby. The home aims to provide a domestic environment promoting independence and dignity. People living in the home receive care and support to live as ordinary a life as possible in the community. The manager at the home is Amanda Jeffries, who was registered as the manager of the home in January 2005. The registered provider is the Worcestershire Mental Health Partnership NHS Trust. The responsible individual for the Trust is Ms Ann Bennington. The Trust has been the registered provider since July 2004. The home’s service users’ guide states that its current charges are £785 per week. Extra charges are made for items such as toiletries, transport, holidays, hairdressing and chiropody. DS0000061835.V372165.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 the service is 1 star. This means the people who use this service experience adequate quality outcomes. This was a Key Inspection. This means that we (the Commission for Social Care Inspection) checked all of the standards that have most impact on service users. It was unannounced, which means that the home manager and staff did not know we were coming. This report includes what we found during the visit to the home, as well as any relevant information that we have received about the home since the last inspection. We were in the home from 12.30 p.m. until early evening. We met and talked with the people living in the home and with several staff on duty. The registered manager was not in the home, although she did offer to meet with us if necessary. We looked at the building and whether it is well kept and safe. We checked records that staff keep, for example about what care they are giving to the people living in the home. We looked at what had changed since the last inspection. What the service does well: The home makes sure it knows what care people need, before and after they move into the home. Staff know how to give the support that is needed with people’s physical and mental health. People living in the home can lead ordinary lives. Staff do not restrict their freedom. Daily life is varied, visitors are welcome, and the food is good. People go out of the home to a variety of different activities in the community. People living in the home know they can tell staff if they have a problem, and staff know what to do if this happens. The home provides a comfortable and homely environment. Staff are well trained and qualified, so they know how best to support the residents. They do not start work in the home unless proper checks have been done, to make it less likely that poor quality staff work there. DS0000061835.V372165.R01.S.doc Version 5.2 Page 6 The manager is experienced and people living in the home like her. The home checks what it is doing on a regular basis, to see how it can do things better for the residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000061835.V372165.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 DS0000061835.V372165.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may want to move into the home can get clear information about the home and the service provided there. Before they move in, the home will make sure it checks what support they need and if the home can provide this support. EVIDENCE: We saw the statement of purpose and the service users’ guide, both of which had been updated in November 2007. They were clearly written, and accessible to people living in the home. Since they were written, the contact details for the Commission for Social Care Inspection (CSCI)(included in the service users’ guide) have changed, so should now be amended. No new people had moved into the home since April 2006. The home had a thorough assessment procedure, including gathering a range of information relating to the prospective service user. This would include information relating to their background, needs and aspirations, likes and dislikes. This information would be gathered from all those involved in supporting the DS0000061835.V372165.R01.S.doc Version 5.2 Page 9 prospective service user. This may include other relevant professionals, family members, previous carers and the individual themselves. As part of the assessment process the home always considered the prospective individual’s compatibility with the existing resident group and has only accommodated individuals whose needs can be met by the service. Previous inspections have found that people had full assessments of their needs before admission. DS0000061835.V372165.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. Staff work with people living in the home to decide what care and support they need. This support is clearly recorded so staff know how to give the right support that people want and need. People living in the home make their own decisions as much as possible. They can live ordinary lives. Staff do what they can to keep people safe, without interfering unnecessarily in their lives. EVIDENCE: We looked at some care plans and risk assessments. We also talked to people living in the home and to staff, about the care people need and about how staff provide the care. We observed how care was provided during the inspection. People who lived at the home had an individual plan of care, which identified their specific needs in relation to care and support. Each individual had a DS0000061835.V372165.R01.S.doc Version 5.2 Page 11 named key worker who had some responsibility for ensuring that assessed needs were being met. The care plans included the aims, aspirations and goals of those who live at the home and details of how the home would support each individual in achieving these. Examples of individual aspirations included: • • • doing yoga learning to use a computer developing independence skills, such as managing money These plans were being reviewed monthly, together with the person the plan belonged to. Progress notes were kept for each plan, so it was easy to see what support was being given and how the person was progressing towards meeting their goals. This was good practice. In addition, a six-monthly review meeting was held for each individual. The home invited all relevant professionals from outside the home, such as social worker, consultant, GP, and family members (if the person wanted) to the meeting with the individual, to review and address any changing needs or aspirations. Evidence was recorded in the plans of care, which showed individuals were assisted in making decisions about their lives, and this was confirmed from conversation with people living in the home. Some individuals had complex and challenging needs; where appropriate individual risk assessments had been carried out. These had been updated and reviewed since the last inspection, and were now clear about what action was needed to manage particular risks to people living in the home. At the time of the inspection, the plans of care were held on computer, but were also being printed when updated to ensure they were easily accessible at all times. People living in the home signed their names to record that they had been invited to assist with their care plans, and to show whether they had been involved. DS0000061835.V372165.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, 14, 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 living in the home lead varied and independent lives, and take part in a variety of activities in the community. Daily life in the home is flexible, and does not stick to fixed routines. Family and friends are welcome in the home, and people living in the home like the food. EVIDENCE: We talked to people living in the home and staff. We looked at care plans and records of activities. We saw food being prepared and looked at menus and records of food provided. We found that people living in the home attend various educational, occupational and leisure activities on a full or part-time basis, some within DS0000061835.V372165.R01.S.doc Version 5.2 Page 13 specialist care services and some within the wider community. Examples of these included: • • • • • • Access to community based specialist mental health services Going to yoga Attending football matches Going out for meals Attending day care settings Visits to local attractions e.g. the Black Country Museum Records were being kept so staff could easily see what activities (including ordinary day to day things like visiting the shops) each person had done. This helped staff to be aware in case anyone needed extra support with their chosen lifestyle. Staff were available on some evening shifts each week so people living in the home could go out supported by staff in the evening, if this was required. Staff and people living in the home confirmed that family and friends are welcome to visit; individual bedrooms can be used for privacy during visits. The home had a telephone that could be used in private. People living in the home said they receive their mail unopened and that they have keys for their bedrooms. All those who live at the home were registered to vote and were supported to do so if they wish. The ethos of the home is to support individuals to be as self-caring as they are able, to encourage independence and empowerment according to individual need. Staff provided assistance with developing social and domestic skills, and we saw some care plans that focused on increasing independent living skills, such as cooking, money management and taking doing their own laundry. Mealtimes were flexible. People living in the home got their own breakfast, with assistance and support from staff where necessary. Individuals took turns to prepare and cook the evening meal, with staff support where needed, and staff cook Sunday lunch. Individual risk assessments were in place for domestic and catering tasks. During the inspection the kitchen area was seen and was well stocked. The shopping had just been brought in. There was a good range of food including fresh vegetables and fruit. People living in the home said they liked the food. There were many compliments from the in the Complaints / compliments book, about how good particular meals had been. Staff also encouraged healthy eating, and evidence of this was seen in the notes from residents’ meetings, where menus were discussed. DS0000061835.V372165.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. Staff know, and keep good records of, what support residents need with their personal care and their health needs. This means that people living in the home get the support they need. Medication belonging to people in the home is usually looked after by staff in a safe way, which helps to reduce the chance of a resident getting the wrong medication. Some improvements could be made to make it safer. EVIDENCE: We talked to staff and people living in the home, and looked at care plans and medication records. People’s personal support, physical and emotional health care needs were detailed and up to date in their plans of care, so staff always knew what support each person needed. Plans of care seen during the inspection gave clear details of health care needs and personal care support needs, and were up to date. For example, a plan DS0000061835.V372165.R01.S.doc Version 5.2 Page 15 for supporting someone with their hygiene included details of how often to remind them, and what type of bath or shower they preferred. Support is provided for individuals to access community health services such as optician, chiropodist, dentist, and audiologist. Mental health reviews are held as necessary with community mental health professionals. Any such appointments were monitored and recorded. The home had written policies and procedures in place for the administration of medication. Staff were administering a range of medication from prescription drugs to household medication. At the time of the inspection, none of the people living at the home were self-medicating. This had been properly assessed to see if any individual would be able to take their own medication reliably and safely, to protect their mental health. Staff had received training in the administration and safekeeping of medicines. The home has access to pharmacy advice via the trust pharmacist. We saw records of medication received in the home, administered to residents, and returned to the pharmacy (if no longer needed.) Most were satisfactory, with some good practice advice given on the day. Some medication had been prescribed, but not yet printed on the MAR (medication administration record) chart from the pharmacy. The instructions had been hand written, but it was not clear who by. Such instructions should be signed by a senior person in the home to ensure their accuracy and their authenticity. Another hand written instruction had been made twice on the same chart, in order to keep one month’s entries together, but this was confusing and a potential cause of error, which would be particularly serious with this type of medication. Medication was mostly stored safely, but there was no dedicated storage for controlled drugs. The home did not have any and was unlikely to do so, but it is now good practice to have this storage available. A delivery was kept in a locked holding area until the senior staff arrived to book it in and lock it away. Arrangements should be made to ensure that a staff member, who is competent to book in and correctly store the medication in the dedicated medication cupboard, is always in the home when the delivery arrives, to ensure medication is always held safely and to prevent any unauthorised use of medication. DS0000061835.V372165.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): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home know they can tell staff if they have a concern or complaint, and feel confident staff will act on it. Staff know what to do if they have any concerns about any person living in the home. EVIDENCE: We looked at records of concerns and complaints, and talked to people living in the home about how the home manages concerns raised by people living there. We also saw the home’s policy on handling complaints. The home had a suitable policy on responding to concerns and complaints. There had been no complaints received by the home, or by CSCI, since the previous inspection. People living in the home said they would speak to staff or the manager if they had a concern or complaint, and felt that staff would do something about it. We looked at the home’s policy on managing concerns about possible abuse of people living in the home, and records of staff training about this. We talked to staff about their understanding of the issue. There was a suitable adult protection policy, which reflected local multi-agency vulnerable adult guidelines. All staff had received training in the protection of vulnerable adults from abuse or self-harm and were aware of the requirement to report any concerns, and not to investigate them within the home unless directed to by the local authority safeguarding coordinator. No adult protection issues had been reported since the previous inspection. DS0000061835.V372165.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is mostly clean, comfortable and well maintained, but repairs do not always get done as quickly as they should, even where they could be a risk to people living in the home. EVIDENCE: The home is mostly well maintained and kept in a safe condition for people who live there. However we saw a fire risk assessment from May 2008, which identified actions needing to be done to reduce “significant risks”, such as replacing smoke seals on fire doors, and replacing a fire door with an excessive gap underneath it. These actions had not yet been done by the Trust, although they had completed the actions needed to reduce “high risks”. A lounge carpet was badly frayed and was a clear trip hazard. This had been reported 6 weeks earlier to the Trust, but not yet replaced. DS0000061835.V372165.R01.S.doc Version 5.2 Page 18 One bathroom had a badly crumbling wall and a handrail attached to it was loose; the room was in need of repair and redecoration. There was an external smoking room, in a converted shed in the garden. This was undecorated and we asked about the possibility of the walls containing asbestos. Staff on duty believed they had been checked for asbestos, but could find no written evidence of this. The rest of the home was pleasant and comfortable, with a choice of lounge, a dining area and a garden. Residents arranged their rooms as they wanted. The home was clean and hygienic. Staff had all completed infection control training, and all but one (who was due to do this) had food hygiene training. This is good practice as it will help reduce the risk of infections among the people living in the home. DS0000061835.V372165.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are qualified, and people living in the home like them. They get the training they need to provide good support to people living in the home. The home does the right checks on people before they start work in the home, to reduce the risk of unsuitable people working with the residents. EVIDENCE: We talked with staff and with people living in the home. We looked at the staff rota and at records of staff training and recruitment. The staff team is well established and experienced. People living in the home said staff were approachable and that they felt comfortable in their company, listened to and supported. Four of the five support workers had attained NVQ level 3, (supporting independence). The registered manager continues to work towards achieving the registered manager’s award and NVQ level 4, and is aiming to achieve this DS0000061835.V372165.R01.S.doc Version 5.2 Page 20 by the end of 2008. Such qualifications help to ensure that people living in the home have the benefit of staff who know what is good practice. Records of staff recruitment checks were seen at the previous inspection in March 2008 and found to be complete except for a photograph of a staff member. This had been corrected. There had been no new staff recruited since then. The right checks reduce the risk of recruiting staff who may be unsuitable to work with the residents. Staff training was well organised, with a clear and up to date training matrix available. This helped the manager to easily see who needed training, and to prioritise it accordingly. For example, all but one care staff had training in management of actual or potential aggression. This helped to keep the staff team up to date with good practice when working with the residents. DS0000061835.V372165.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is experienced and competent, and well liked by staff and people living in the home. The home regularly checks what it is doing, to see what can be done to make the service better for the residents. The home is mostly kept safe for people who live there, but sometimes delays in repairs getting done means that it is not as safe as it should be. EVIDENCE: The manager is an experienced practitioner who has managed the home since 2004, and managed another home before then. She is a qualified registered mental health nurse. She has not yet completed the Registered Manager’s Award and NVQ level 4, but is aiming to do so by the end of 2008. DS0000061835.V372165.R01.S.doc Version 5.2 Page 22 People who live at the home and staff all spoke well of the registered manager, for example saying she was “Open”; “Excellent. She keeps an eye on us but gives us independence”; and “She looks after us very well.” The home has a full quality assurance system in place, which includes surveys to find out what people living in the home, relatives and external professionals think of the service provided. A six monthly service review is now held from which a quality monitoring report is produced. We saw a summary of this report. The purpose of the review is to assess progress made during the previous six months in meeting key objectives. Areas covered by the review include staffing, concerns and complaints, health and safety, aims and objectives. The home has an annual development plan, which forms part of, and is linked to, the quality assurance and monitoring systems. The plan provides a way in which the service is able to identify areas of strength and weakness, create an action plan and monitor improvements based on feedback from consultation or auditing processes. Within the home, routine safety checks and tests were being done regularly; we saw evidence of up to date checks including fire safety tests, fire drills, temperature tests on fridges and freezers, water temperatures, cleaning of kitchen equipment, gas safety and electrical safety certificates. There had been some delay from the Trust in making repairs that had been identified as necessary to reduce the risks to people living in the home. We saw a fire risk assessment from May 2008, which identified actions needing to be done to reduce “significant risks”, such as replacing smoke seals on fire doors, and replacing a fire door with an excessive gap underneath it. These actions had not yet been done by the Trust, although they had completed the actions needed to reduce “high risks”. A lounge carpet was badly frayed and was a clear trip hazard. This had been reported 6 weeks earlier to the Trust, but not yet replaced. The Trust, as the registered provider, needs to act promptly to ensure the safety of people living in the home. DS0000061835.V372165.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 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 2 25 X 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 1 X DS0000061835.V372165.R01.S.doc Version 5.2 Page 24 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 Written instructions about medication must always be accurate. This will help to reduce the risk of resident receiving the wrong medication. Timescale for action 31/10/08 2 YA42 13(4)(a) and (c) 31/10/08 Where action is identified as necessary to reduce significant risks, it must be carried out promptly. Specifically, the actions needed to reduce the risk of fire and the risk of tripping must be completed without further delay. This will help reduce the risk of fire or accident to people living in the home. 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 YA1 Good Practice Recommendations The home should update any written information with the DS0000061835.V372165.R01.S.doc Version 5.2 Page 25 current CSCI contact details. 2 YA20 Where an entry on a MAR (medication administration record) chart is handwritten, it should be checked and signed by a suitable senior staff member to ensure it is accurate and is properly authorised. The home should consider obtaining dedicated CD (controlled drugs) storage. Arrangements should be made to ensure that a staff member, who is competent to book in and correctly store the medication in the dedicated medication cupboard, is always in the home when the delivery arrives, to ensure medication is always held safely and to reduce the risk of unauthorised use of medication. The risk of asbestos in the home, specifically in the smoking room, should be assessed and any necessary actions taken to address any risk. 3 4 YA20 YA20 5 YA42 DS0000061835.V372165.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 DS0000061835.V372165.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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