Inspection on 13/06/07 for 63-65 Bardsley Drive

This inspection was carried out on 13th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

63-65 Bardsley Drive 27/07/09

63-65 Bardsley Drive 10/06/08

63-65 Bardsley Drive 18/10/05

63-65 Bardsley Drive 19/04/05

63-65 Bardsley Drive 02/09/04

63-65 Bardsley Drive 06/04/04

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Insight - Eastchurch

Southfields

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33 St John`s Church Road

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

CARE HOME ADULTS 18-65 Bardsley Drive (63/65) Bardsley Drive 63/65 Bardsley Drive Farnham Surrey GU9 8UQ Lead Inspector Lisa Johnson Unannounced Inspection 13th June 2007 09:30 Bardsley Drive (63/65) DS0000013525.V338974.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 Bardsley Drive (63/65) DS0000013525.V338974.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. Bardsley Drive (63/65) DS0000013525.V338974.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bardsley Drive (63/65) Address Bardsley Drive 63/65 Bardsley Drive Farnham Surrey GU9 8UQ 01252 727148 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) zoe.measures@tactsouth.org Thames and Chiltern Trust Ltd Ms Zoe Measures Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Bardsley Drive (63/65) DS0000013525.V338974.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be 35-65 YEARS One of the persons accommodated may be within the category (MD) in addition to being within the category (LD) There must be one to one support to the named service users 24hours (including `sleeping nights` during his stay at the home. 18th October 2005 Date of last inspection Brief Description of the Service: 65/67 Bardsley Drive has been developed from two independent semi-detached houses to an integrated establishment whereby the some of the facilities are shared. It provides accommodation for 3 adults with learning disabilities. The house is located in a quiet residential road and within walking distance of Farnham town centre. The home has its own transport to support service users to access the wider community. There is off street parking at the front of the property, for two vehicles. The bedrooms are all sited upstairs in both halves of the house. In addition, the ground floor area in both houses has a kitchen/diner and comfortable sitting room. The rear garden of the house Is made up of one large patio area, with garden furniture. This is used as additional communal area, particularly in the summer months. Age range of persons accommodated 18-65years. The weekly fees range from £1,040- £2,16.00 Bardsley Drive (63/65) DS0000013525.V338974.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The site visit was unannounced and took place over five hours and forty-five minutes commencing at nine thirty am and finishing at three fifteen pm. Mrs. L Johnson Regulation Inspector carried out the visit and Ms. Z. Measures Registered Manager represented the establishment. The inspector spoke to two people who live in the service to gain their views on the care provided. One comment card was received from a health care professional and three comment cards were received from people using the service and these comments have been reflected in this report Information was gained from the Annual Quality Assurance Assessment (AQQA) provided by the registered manager prior to this visit. During this visit a tour of the premises took place. Care plans, staff training records, staff files and policies and procedures were sampled. The inspector also spoke with two members of staff. The inspector would like to thank the people living in the service and staff for their time, assistance and hospitality during this visit What the service does well: The service provides a homely, relaxed and friendly atmosphere. Positive relationships were observed between people using the service and staff. Comments received included, “ The staff listen a lot” and “I like living at the home”. Each person in the home has a detailed person centred and health action plan which is completed in consultation with individuals. People are supported to make decisions and choices about their lives. The inspector spoke to one person who said, “we have meetings” and “I choose what I want to do”. People living in the service are provided with the opportunity to assist in staff recruitment. People living in the service are supported to have a range of activities and lead active lives. One person has a gardening job and have the opportunities to attend college. All people using the service have three annual holidays. Comments received include, “I do lots of things like riding, going to the library and going to the pub”. “I play snooker”. People living in the home have the opportunity to be involved in household tasks. One person said, “I am a good cook and I cook the breakfast on Saturday and I take turns to do the vacuuming” and “I keep my room clean with help”. Bardsley Drive (63/65) DS0000013525.V338974.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bardsley Drive (63/65) DS0000013525.V338974.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 Bardsley Drive (63/65) DS0000013525.V338974.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 &3 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are provided with information to enable them to make an informed choice about the suitability of the service as a place to live. Policies and procedures are in place that ensures that the needs of prospective people moving into the home will be assessed prior to admission to the home. EVIDENCE: The service has a statement of purpose and service users guide providing information detailing the services to be provided. The guide is also formulated in large print and the manager has also provided this information on a tape ensuring that it is accessible to people using the service who are unable to read. The home has an admissions procedure in place. Community care assessments obtained from care managers were available and the inspector viewed the pre- admission assessment that was completed by the manager for the last person moving in to the service. The manager stated that prospective individuals would have the opportunity to visit the home and that they would have the opportunity spend time with other Bardsley Drive (63/65) DS0000013525.V338974.R01.S.doc Version 5.2 Page 9 people already living in the home. One individual commented, “”I visited the house lots of times to meet everyone to see if I liked it”. Bardsley Drive (63/65) DS0000013525.V338974.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 People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service are provided with an individual care plan, which records their individual needs and goals. People are supported to make decisions about their lives with assistance and are supported to take risks as part of an independent lifestyle. EVIDENCE: Each person has a completed care plan, which has been based on a full needs assessment and skills assessments. Individual plans were person centred in their approach detailed and structured with clear objectives and goals. Plans have been discussed and agreed with each individual living in the home and were regularly reviewed. The manager said that she is planning to introduce monthly meetings with each individual and their key worker, which would include a review of the care plan. Two members of staff spoken with during this visit confirmed that they were aware of each individual’s plan. Bardsley Drive (63/65) DS0000013525.V338974.R01.S.doc Version 5.2 Page 11 People using the service are consulted and supported to make decisions about their lives with assistance where required. This was confirmed by one individual who said, “ We have regular meetings to talk about things”. People living in the home are provided with the opportunity to be involved in the staff selection process. The inspector was informed that people attend self-advocacy sessions run by an advocacy organisation. The home has adapted information into user-friendly formats and the communication needs of each person are recorded in their care plan. People living in the service have received training in fire awareness and diversity training and the home is planning to conduct food hygiene training. Where people require support with their finances this was recorded in their individual care plan. People using the service are supported to take part in a range of activities. Comprehensive risk assessments and guidelines were included in each individual’s plan, which were sampled, including for example emotional support community access, road safety, personal hygiene and bathing. All risk plans had been signed by staff to confirm that they were aware of the risk plans and guidelines. Bardsley Drive (63/65) DS0000013525.V338974.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 People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that people using the service are provided with a range of appropriate activities and engage in a range of leisure activities. People are supported to take part in the local community and their rights and responsibilities are respected. The home is able to demonstrate that service users are provided with a well-balanced and nutritious diet. EVIDENCE: The home supports people to access a wide range of meaningful activities, which meets their needs and preferences. During this visit one individual said he has a gardening job and showed the inspector a City in Guilds certificate he had obtained and another certificate in horticulture. Another individual said that he attends college and showed the inspector his certificate that he had obtained for cookery. People using the service participate in a number of social activities and events. One person said, “I have a bike and I play snooker”. Another individual showed Bardsley Drive (63/65) DS0000013525.V338974.R01.S.doc Version 5.2 Page 13 the inspector photographs of some of the activities that he participates in. Other comments received included, “I can do what I want”: “Sometimes I go to the pub and on Saturday I go to the farm”; “I do lots of things, riding and going to the library”. People living in the home are provided with three annual holidays and two individuals told the inspector about their holidays which they had been on. One break consists of hiring a castle, which includes participating in an Elizabethan banquet, and one individual spoke positively about this experience. People have the opportunity to participate in National Trust land for walks and one individual told the inspector he attends church every week. People living in the home are fully involved in household activities. One person said “I am a good cook and I cook fried breakfast on Saturday and I take turns to do the vacuuming”. Other comments received included, “I keep my room clean with help”. During this visit two people left the home to shopping with staff and one person told the inspector about the items he was going to purchase. People living in the home are supported to maintain links with their family and friends and two people spoken with told the inspector about their relatives. People are supported to write letters and send postcards from their holidays. The inspector was informed that one person maintains links with friends The home provided a friendly, relaxed and happy atmosphere. Positive relationships were seen between people living in the service and staff who were interacting throughout this visit. Two people were seen playing cards and board games with staff. One person chose to spend some time alone in his room listening to music and his preference to choose this was respected by staff. Each individual is provided with their own key for their bedroom and the front door. People living in the home were observed to have access to the kitchen and making them self’s hot drinks. People living in the home choose their meals on a weekly basis and are involved with shopping. The main meal is served in the evening therefore the inspector was unable to view this. However records of meals eaten were recorded in individual’s daily diaries and were seen to be varied and well balanced and fresh fruit was available in the kitchen. Bardsley Drive (63/65) DS0000013525.V338974.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that people using the service receive personal support in the way they prefer and their physical and health needs are met. Service users are protected by the homes medication administration procedures. EVIDENCE: Service users person centred plans consisted of detailed and comprehensive information including “All about me”, “Things you can help me with” and “how I like to look” which clearly identifies individuals preferences. During this visit one individual was observed to be supported in using the computer to prepare a planning list for his holiday. The health care needs and objectives of service users were identified and the support individuals require was clearly documented in their health action plan which also confirmed that people using the service are supported to access a range of health care professionals including a local General Practitioner, dentist .One person wears glasses and is supported to access the optician. Another individual has mental health needs and the home works in conjunction with the community mental health nurse. One individual told the inspector about some Bardsley Drive (63/65) DS0000013525.V338974.R01.S.doc Version 5.2 Page 15 of the health care professional support he receives. Detailed records were maintained of all health screen checks and consultations. A comment received from a health care professional stated, “the carers I have met are attentive and caring”. The homes medication administration systems were examined. A medication administration procedure was in place and a list was available for all staff that are trained and authorised to administer medication. All medication administered had been signed for. Risk assessments were in place for individuals who wish to self medicate. One matter was identified that needed improvement. It was observed that some medication had been hand transcribed on to the medication administration record, which had not been signed or dated by the author. An immediate requirement was made that matter must be attended to. During this visit the manager responded to this matter ensuring that this requirement was completed. It was also recommended that a second member of staff should also check and sign this as good practice to safeguard people using the service. It was also recommended that the manager consider arranging for the pharmacist to visit the home to conduct an up to date audit. Bardsley Drive (63/65) DS0000013525.V338974.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The views of people using the service are listened to and acted upon. One matter needs attention to ensure that they are fully safeguarded from abuse EVIDENCE: There is a complaints procedure in place which is accessible to service users in picture format and included in the service user guide which is also available on tape. The manager also keeps complaints register. Four comment cards received from people using the service all state that they are aware of how to make a complaint and one individual spoken with said, “Staff always listen” and another comment received stated, “I like living at the home”. Staff training records sampled indicate that they have received training in safeguarding adults from abuse and the manager has attended the local authority safeguarding adult training. The home has a safeguarding adult from abuse and whistle blowing policy, although it was required that the manager must obtain the updated version of the local authority multi- agency safeguarding adults from abuse policy. During this visit the inspector spoke with two new members of staff who were aware of the procedures and were clear in their responses as to the action they must take if they were ever to witness any abuse Bardsley Drive (63/65) DS0000013525.V338974.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 & 30 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home have a well-maintained, safe, comfortable, homely and clean environment. To live-in EVIDENCE: The home has been developed from two independent semi-detached houses to an integrated establishment whereby the some of the facilities are shared. Each house has their own sitting room and kitchen, which have been refurbished. The service provides a homely atmosphere. During this visit the home was found to be well maintained and pleasantly furnished. although some improvement is required to the décor of the bathrooms and a toilet seat was broken. This matter was discussed with the manager who stated that this work has been planned and is to take place shortly. Two bedrooms viewed during this visit were comfortable and reflected individuals preferences and interests with a wide range of personal possessions on display. Bardsley Drive (63/65) DS0000013525.V338974.R01.S.doc Version 5.2 Page 18 An accessible garden is available to the rear of the house, which is patioed and contained flowerbeds and garden furniture. During this visit people were seen to be using this facility and one individual said that helps plant the flowers The home was cleaned to a good standard and was hygienic. Staff receive training in infection control and the service has an infection control procedure, which is based on the Department of Health guidance. Bardsley Drive (63/65) DS0000013525.V338974.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 &36 People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Competent and qualified staff support people using the service and they are protected by the homes recruitment policy and practices and their needs are met by appropriately trained staff. EVIDENCE: Adequate staffing levels are maintained in the service. Staff turnover has been minimal and the home has recruited a number of new staff. The home does not use agency staff. The home also employs social work students on a temporary basis. Each member of staff has a job description and has been issued with the General Social Care code of conduct, which was confirmed by one member of staff spoken with. The manager has stated that she would like to recruit more male members of staff to balance the gender group. Each member of staff has their own training record in place and it was evident that staff have received mandatory training in safeguarding adults, fire awareness, food handling, health and safety and food hygiene. The manager stated that she is also the training coordinator for the company and has Bardsley Drive (63/65) DS0000013525.V338974.R01.S.doc Version 5.2 Page 20 completed a number of courses to be a trainer in a range of subjects and is also part of the Surrey Skills for Care sub group. The home is able to demonstrate that staff receive training and development, which actively supports the needs of people using the service such as engaging the mental health team to conduct training in mental health and dementia awareness. Information provided by the manager indicates that eighty percent of staff that work in the service hold National Vocational Qualifications with the manager stating that the deputy manager is planning to undertake the National Vocational Qualification (level4). New staff receive induction, which is based on the Skills for Care core induction standards. The company has an equal opportunities and recruitment policy in place. The inspector was informed that people who live in the service are involved in the staff selection process and the inspector viewed some of the written questions that people using the service had recorded which they wished to ask. Three staff personnel files were sampled which contained the required information including two references, evidence of POVA first and an enhanced Criminal Records Bureau check. Staff receive regular formal supervision which was seen by records kept on individuals files and was confirmed by a member of staff spoken with and each person has personal development plan Bardsley Drive (63/65) DS0000013525.V338974.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that people using the service benefit from a home, which is well run, and in their best interests. The health safety and welfare of service uses is mainly protected with two matters needing attention. . EVIDENCE: The registered manager has experience of working in social care and supporting people with a learning disability and she has also completed the Registered Managers Award. There was an open atmosphere in the home and the manager was observed to be accessible. Two members of staff spoken with during this visit stated that felt supported by the manager and that it was a positive place to work. The home conducts quality assurance surveys, which have been recently updated. The responsible individual conducts monthly Bardsley Drive (63/65) DS0000013525.V338974.R01.S.doc Version 5.2 Page 22 quality visits with the reports maintained in the home, which were viewed during this visit. The home holds regular meetings in consultation with people using the service. There was a range of policies and procedures in place, which are all being reviewed. Staff spoken with during this visit stated that these have been brought to their attention and a read and sign system was in place. Health and safety checks are regularly conducted and fire records were appropriately maintained. Information provided by the manager in the Annual Quality Assurance Assessment and certificates sampled during this visit indicate that routine service and maintenance arrangements for the environment and equipment take place. Accident records were sampled which were appropriately recorded and maintained. Two matters were identified that need improvement. A record book is maintained for the recording of water temperatures and it was observed this had not been kept up to date. A requirement was made that this matter must be attended to. During a tour of the home it was observed that radiators throughout the home were not provided with covers. Therefore it was required that a risk assessment is conducted ensuring the health, safety and wellbeing of people using the service. Bardsley Drive (63/65) DS0000013525.V338974.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 4 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 34 35 36 4 4 X 3 X LIFESTYLES Standard No Score 11 12 13 14 15 16 17 X 4 4 X 3 X 3 X 4 4 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000013525.V338974.R01.S.doc Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bardsley Drive (63/65) Score 4 4 2 X 3 X 3 X X 2 X Version 5.2 Page 24 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 YA23 Regulation 13(6) Requirement Timescale for action 27/06/07 2 3 YA42 YA42 A copy of the updated local authority multi agency safeguarding adults from abuse procedure must be obtained. 13(4)(a)(c) The water temperatures in the home must be recorded on a regular basis 14(4)(c) A risk assessment must be conducted in respect of the unguarded radiators 20/06/07 27/07/07 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 2 Refer to Standard YA20 YA20 Good Practice Recommendations It is recommended that where medication is hand transcribed on to the medication administration record this should be checked by two members of staffIt is recommended that the manager arranges for the pharmacy to carry out an up to date audit Bardsley Drive (63/65) DS0000013525.V338974.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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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