Inspection on 16/08/07 for Azalea House 2

This inspection was carried out on 16th 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Azalea House 2 24/10/08

Azalea House 2 16/07/08

Azalea House 2 07/09/06

Azalea House 2 15/05/06

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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

CARE HOME ADULTS 18-65 Azalea House 2 69 Winifred Road Bedford Bedfordshire MK40 4EP Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 16th August 2007 12:30 Azalea House 2 DS0000066691.V342509.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 Azalea House 2 DS0000066691.V342509.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. Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Azalea House 2 Address 69 Winifred Road Bedford Bedfordshire MK40 4EP 01234 342215 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) Minster Pathways Limited Jan West Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th September 2006 Brief Description of the Service: Azalea Services are two privately owned care homes situated in a residential street on the west side of Bedford. The two adjacent houses operate in conjunction with each other. House 1 is registered for 4 service users who have a diagnosis of learning disabilities and mental health needs; house 2 is registered for 3 people in the same category. The purpose of the service is to offer appropriate support for service users, including developing or maintaining their independence skills. The house is a domestic property and offers single bedrooms, a lounge; bathing facilities, staff sleeping room, a dining room, and a kitchen. There is a rear garden at the back of the two homes, fenced off separately. The common office to both the homes is located in an extension in one of the back garden. The house is located approximately one mile from the town centre and within walking distance of local shops, pubs, and transport links. The fee quoted by the manager was in the range of £700-£1300. Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 16/08/07 by Pursotamraj Hirekar over 5 hours. The manager and the senior staff coordinated the inspection. The method of inspection included study of care plans, risk assessments, personnel records, staff deployment duty rota, relevant care delivery documents, discussions with manager and staff, conversation with service users’ and partial tour of the building. The annual quality assurance assessment self-assessment information provided by the home is included for analysis and preparation of this report as well. What the service does well: What has improved since the last inspection? What they could do better: The home must confirm in writing to the service user that the home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare; and a copy of the needs assessment is made available on inspection. The home must ensure to have an appropriate risk assessment and an improved action plan for a service user who was not at home on the 11/08/07, to prevent unanticipated incidents and help develop the service user to lead an independent and meaningful life. The home needed to explore and make appropriate arrangements and develop service user specific individual activity plans that meet their lifestyle needs. The home must ensure and support for service users to make use of services, facilities, and activities in the local community. The home need to have appropriate mechanism to monitor and ensure the medication was administered to the service users as prescribed and recorded correctly. Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 6 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. Azalea House 2 DS0000066691.V342509.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 Azalea House 2 DS0000066691.V342509.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 adequate. This judgment has been made from evidence gathered during the inspection, which included a visit to the service. The admission procedure, including written information, to provide service users with an opportunity to make an informed choice and decision was good. However, the home needs to make sure that the pre-admission assessment of new service user is made available during the inspection. EVIDENCE: The home had made appropriate arrangements for the assessment of needs and aspirations of the service users’ prior to their moving to the home. On this inspection 3 service users’ were case tracked and found that all the 3 the service users’ had prior information and an opportunity to test drive the home to make an informed choice that the home they choose will meet their needs and aspirations. The preadmission assessment of 2 service users included; basic practical independent assessment- covering bedroom, bathroom, kitchen, clothes and laundry, money and finances, clinical, mobility, health and safety, travel and their signed contracts were on the file. The home had 1 new admission on the 10/08/07. The manager informed on the inspection that pre-placement assessment took place to determine whether the home can meet the needs of the potential service user. However, preadmission needs assessments documentation was not available on this inspection, as they were at the head quarters of the company, the manager Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 9 informed. The file had information about basic practical independence assessment dated 16/08/07 and likes and dislikes. The service user contract was not signed. Service user said ‘ I made trial visits to see if I liked it, and I am happy to be in this home’. Azalea House 2 DS0000066691.V342509.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 adequate. This judgment has been made from evidence gathered during the inspection, which included a visit to the service. The home had made adequate arrangements for assessments of individual needs and choices of service users. However, appropriate risk assessment and an improved action plan is required for a service user who was not at home on the 11/08/07, to prevent unanticipated incidents and help develop the service user to lead an independent and meaningful life. EVIDENCE: The home had made adequate arrangements for assessments of individual needs and choices of service users. The home had developed care plans and reviewed regularly. These care plans were based on the needs and risk assessments of individual service users’ that focussed on service users’ goals as well. The home was planning to develop service user guide and care plan in a user-friendly format that enable service users to understand better. The home was making efforts to encourage service users to attend service users meeting to improve the service delivery. On this inspection 3-service users care records were seen and their summary is as follows: Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 11 Service user –1 prospective service user assessment form was comprehensive. The care plan detailed functions for the bedroom, the bathroom the kitchen, clothes and laundry, money and finances, clinical, mobility, health and safety, travel. The personal care plan was structured under objective, action plan and outcome for the following elements: Living arrangements and personal support, family and social contact, employment and education opportunities, leisure and recreation, physical and mental health, assessment and management of risk, cultural and spiritual/ faith needs, aggression/self harm, eating and drinking, mobility, communication methods, specific conditions – related needs and specialist input, disability equipment, sleep and night, dying and death, compatibility with others living in the home, income/finances, any restrictions on choices and freedom imposed by specialist programmes – the service user is subject to enhanced CPA and section 117 of MHA 1983. The manager signed the care plan and there was no signature of the service user. In addition to care plan, the home had developed goal specific plan, which was supported by a monthly review process. The goal plan covered; living arrangement and personal support need, family and social contact, employment and educational opportunities, physical and mental health, assessment and management of risk, eating and drinking, leisure and recreational need. The service user risk assessment of 02/02/07 covered; risk of exploitation, risk of violence or harm to others, suicide and historical sign, deliberate self harm, injury from vehicles whilst crossing road, slips, trips, falls from fluid/substances on the floor, severe self neglect, inhalation/ingestion of chemical substances, fire, slips, trips, falls due to service users smoking in laundry room in home number 69. CPA review was undertaken on the 01/05/07, service user, key worker, care coordinator, and associate specialist participated. The service user and the care coordinator signed CPA care plan dated 20/07/07. Service user – 2 had basic assessment; covering bedroom, bathroom, kitchen, clothes and laundry, money and finances, clinical, mobility, health and safety, and travel. Personal care plan of 06/08/07 covered details of; living arrangements and personal support, family and social contact, employment and education opportunities, leisure and recreation, mobility, physical and mental health, assessment and management of risk, cultural and spiritual/faith needs, aggression/self harm, eating/drinking, specific condition-related needs and specialist input, treatment and rehabilitation programme, sleep and night, cognitive ability, environment, dying and death, compatibility with others living in the home, personal and household, income/finances, discharged from section 25a MHA 1983 22/5/7. In addition to care plan, the home had developed goal specific plan, which was supported by a monthly review process. The goal plan was detailed under; Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 12 living arrangements, family and social contacts, employment and education, leisure and recreational, financial needs, specific conditions related and specialist input needs to be met, cultural and spiritual needs, eating and drinking, independent in maintaining personal and household needs, cognitive abilities, physical needs and challenging behaviour and risk associated with service user stated - to be assessed, The risk assessment carried out covered areas such as slips, trips, falls, from fluid/substances on floor, fire, choking, burns whilst ironing, physical and verbal abuse by others, challenging behaviour. These risk assessment were reviewed for June and July 2007. On the 11/08/07 the service user went out of the home and had not returned until police returned him on the 12/08/07. The home was aware of the behavioural problems of the service user, nevertheless, appropriate risk assessment and an improved action plan is required, to prevent such incidents and help develop the service user to lead an independent and meaningful life. Service user –3 was admitted to the home on the 16/08/07. The comprehensive care plan, goal plan work was in progress. However, the needs assessments carried out and updated by the social services on the 10/05/07. The file had information with regard to CPA care plan and review notes dated 17/7/7. Risk assessments realting to clinical symptoms, behaviours, treatment related forensic, person related contextual and historical record of risk incidents. Likes and dislikes recorded. Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgment has been made from evidence gathered during the inspection, which included a visit to the service. The home needed to explore and make appropriate arrangements and develop service user specific individual activity plans that meet their lifestyle needs. EVIDENCE: The home needed to explore and make appropriate arrangements and develop service user specific individual activity plans that meet their lifestyle needs. The home needs to further develop variety of in-house and outdoors activities that stimulate and engage service users’ as per their choice and wish. This way, service users needed encouragement to develop their own initiative and the activities. As it was found during the inspection that 3 service users’ refused to do an activity plan and the others spent their time in household chores, watch TV and relaxing. The current activities managed by the home do not provide enough stimulation and help develop independent lifestyles for the service users. One service user said that the home is a nice place to live, but has to many rules. Especially food at night was not available when he feels hungry. Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 14 Service users were observed interacting with each other and with staff, and their relationships seemed friendly and supportive. The home had a dietary plan and menu was prepared on a weekly basis service users had the choice of menu and the food intake was monitored on a weekly basis. The service users’ moved freely between houses and enjoyed that freedom. The service users’ had a designated space for smoking in the rear part of the home and the staffs supported the service users’ to follow. The service users’ had no problem in following the smoking policy of the home. The home had maintained key worker monthly notes, 13/07/07 and 05/06/07 was seen on this inspection. The monthly notes covered details about service user living arrangements, family and social contacts, employment and education opportunities, leisure and recreation, assessment and management of risk, income, specialist input, cultural and spiritual, eating and drinking, personal and household, cognitive ability, physical and mental health, social skills, challenging behaviour/self harm, treatment/rehabilitation programme, environment, sleep and night, mobility, communication, compatibility with others living in the home, and comments from service user. Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgment has been made from evidence gathered during the inspection, which included a visit to the service. The staff encouraged independence, but also supported service users to meet all their healthcare needs. However, The home need to have appropriate mechanism to monitor and ensure the medication was administered to the service users as prescribed and recorded correctly. EVIDENCE: The manager, staff, and the service users’ had good working relationships that enabled service users to freely express their views and receive appropriate care from the staffs of the home. The staff, those of who have received medication training carry out the task of administration of medication to the service users’. The home had maintained records pertaining to the medication, including monthly weight chart of the service users’. The medicine was stored in a safe place. One service user was prescribed sinvastatin tablets 40mg to take one at night. The service user was not present at the home on the 11/8/7 and 12/08/07 and has not received medicine; the medicine was in the doset box. The medication administration record for 14/08/07 recorded refused and no reason for refusal was recorded and the medicine was kept in an envelope with a note saying refusal. For 15/08/07 the medicine was not there in the doset box and there was no recording on the mar sheet, when asked, the staff member signed the mar sheet during the inspection, as medicine administered. Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 16 The home need to have appropriate mechanism to monitor and ensure the medication was administered to the service users as prescribed and recorded correctly. Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgment has been made from evidence gathered during the inspection, which included a visit to the service. The home had an effective complaints policy and procedure that enabled service users to express their opinions and potential dissatisfaction. The home must do appropriate risk assessment and develop an improved action plan for a service user who was not at home on the 11/08/07, to prevent unanticipated incidents and help develop the service user to lead an independent and meaningful life. EVIDENCE: The home had developed policies and procedures that included adult abuse and protection, aggression towards staff, bullying in the workplace, racial harassment, whistle blowing and staff grievances. The home had reported that there were 5 complaints received and dealt with appropriately, since the previous inspection. The staff and the service users spoken to were aware of the home’s complaints procedure. The goal specific plan of a service user recorded under risk associated with service user - to be assessed. On the 11/08/07 the service user went out of the home and had not returned until police returned him on the 12/08/07. The home was aware of the behavioural problems of the service user, nevertheless, appropriate risk assessment and an improved action plan is required, to prevent such incidents and help develop the service user to lead an independent and meaningful life. Azalea House 2 DS0000066691.V342509.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 judgment has been made from evidence gathered during the inspection, which included a visit to the service. The home had made changes to the environment that had positive impact on the service users’ and the staffs’. EVIDENCE: On this inspection partial tour of the premises was undertaken and found that the home was maintained clean and tidy without any offensive odours. The inspection carried out on the 09/07/07 by the fire services indicated inadequate safety training provided to staff, inadequate fire warning system, and inadequate automatic fire fighting equipment maintenance. The home manager had written to the commission regarding the improvements made to meet the requirements made by the fire officer. On this inspection the fire risk assessment record the home had completed for 07/07/07, 30/06/07, 20/06/07, 11/06/07; fire alarm 24/07/07, 09/07/07, 07/07/07; emergency lighting 24/07/07 and 09/07/07. 07/07/07; panic alarm 24/07/07, 09/07/07, 07/07/07 and monthly evacuation check 07/07/07, 07/08/07 was seen. Fire warning system has been extended to provide a sounder in the new office has been installed. However, as recommended by the fire authority, the home Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 19 must ensure regular maintenance, testing and serviced to the standards recommended in the appropriate British standards. Azalea House 2 DS0000066691.V342509.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 good. This judgment has been made from evidence gathered during the inspection, which included a visit to the service. The fully staffed team achieved recently after latest recruitment ensured that consistent and appropriate care was provided for service users. However, the identified training needs of staffs’ needed to be implemented as scheduled to avoid any risk of service users being managed inappropriately. EVIDENCE: The home had undertaken staffs’ training needs assessment and had developed a training plan for staff to undertake the training. Some of these training included NVQ2 &3, first aid, fire safety, infection control, moving and handling, health and safety, medication administration, managing violence and aggression management, safeguarding adults, and diversity. The home must ensure that all staff received appropriate training as planned to ensure better care provision and delivery in the best interest of the service users and avoid any risk of service users being managed inappropriately. The staff records were seen on this inspection; and found that staff –1 had application form, references, crb, pova clearance, contract, and supervision was regular. Staff –2 had references, pova clearance, crb, employment contract, induction form, and supervision was regular. Both the staffs spoken to were polite and appeared to have good understanding of their roles and Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 21 responsibilities. However, both the staffs expressed difficulties communicating in English comfortably with the service users, which they were improving upon. Azalea House 2 DS0000066691.V342509.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 judgment has been made from evidence gathered during the inspection, which included a visit to the service. There has been considerable improvement in the management of the home since the previous inspection. The key to good management of this home was having good working relations with the staff, service users’ and their family members, and relevant professionals. EVIDENCE: There has been a considerable improvement with regard to the management of the home, which has been detailed under various outcome groups. The manager of the home had provided effective leadership and managed the home professionally. The key to good management of this home was having good working relations with the staff, service users’ and their family members, and relevant professionals. The staff and the service users’ spoken to, all have appreciated the way the home was run by the manager. The home had provided information to the commission with regard to various practices that would impact upon the life of the service users’. They included Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 23 safeguarding and fire safety. The home had practised key worker monthly checks, review monthly checklist, preparation of monthly summary, recording on contact sheet, and medical appointments. Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 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 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 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 Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. YA2 Standard Regulation 14 Requirement The home must confirm in writing to the service user that the home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare; and a copy of the needs assessment is made available on inspection. The home must ensure to have an appropriate risk assessment and an improved action plan for a service user who was not at home on the 11/08/07, to prevent unanticipated incidents and help develop the service user to lead an independent and meaningful life. The home needed to explore and make appropriate arrangements and develop service user specific individual activity plans that meet their lifestyle needs. The home must ensure and support for service users to make use of services, facilities, and activities in the local community. The home need to have appropriate mechanism to DS0000066691.V342509.R01.S.doc Timescale for action 30/09/07 2. YA6 15 30/09/07 3. YA12 16 (2)(m)(n) 30/09/07 4 YA13 16(2)(m) 30/09/07 5. YA20 13 (2) 30/09/07 Azalea House 2 Version 5.2 Page 26 6. YA23 13 (6) monitor and ensure the medication was administered to the service users as prescribed and recorded correctly. The home must do appropriate risk assessment and develop an improved action plan for a service user who was not at home on the 11/08/07, to prevent unanticipated incidents and help develop the service user to lead an independent and meaningful life. 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Azalea House 2 DS0000066691.V342509.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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