Inspection on 17/06/05 for Beauly Way

This inspection was carried out on 17th June 2005.

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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beauly Way 23/10/07

Beauly Way 28/06/06

Beauly Way 05/01/06

Beauly Way 11/01/05

Beauly Way 28/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Beauly Way 4 Beauly Way Rise Park Romford Essex RM1 4XD Lead Inspector Rhona Crosse Unannounced 17 June 2005 09:20 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 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 Stationary 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. Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Beauly Way Address 4 Beauly Way, Rise Park, Romford, RM1 4XD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01708 756624 01708 756624 Outlook Care Olayinka Odelola CRH Care Home 6 Category(ies) of LD Learning disbility (6) registration, with number of places Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11 January 2005 Brief Description of the Service: Beauly Way is a purpose built home for 6 younger adults (all males) with learning disabilities and offers 24 hour care. Accommodation is on two floors and all bedrooms are single occupancy. There is a secure garden for service users to use. The home is situated in a residential area of Rise Park and is near to local shops. Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced so the home did not know the inspector was coming. Staffing levels were appropriate at the time of the inspection. There was one requirement made at the last inspection and this has been deal with within the timescale set by the previous inspector. The home was found to be well managed with a team of well trained staff. The manager was at the home for the majority of the inspection but had a prior engagement so the senior member of staff took over when he left the home. Staff were seen to interact well with service users who have complex and sometimes challenging needs. Service users were seen to be treated with kindness and respect by the staff. The inspector looked at care plans, risk assessments, daily records, accidents, infringement of rights forms, activity plans and records, health care needs, medication administration sheets in conjunction with the monitored dosage system for the administration of medication (a requirement was made by the inspector at this inspection about the recording of medication). Other areas inspected were: Staffing employment records, supervision records (dates of supervision taking place), training programmes and training already achieved. An inspection of the premises took place. The majority of the home was clean and free from odours. Bedrooms were full of personal possessions making the rooms look homely. Bathrooms were clean. The kitchen was well maintained. Health and safety records were well maintained and up to date, this also evidences that the home is well managed. What the service does well: The home manages service user’s who have complex care needs very well. At times these can be challenging and incidents are recorded and action taken after advice has been sought from other health care professionals as necessary. Service user’s general health was well documented with visits to GP’s and other health professionals visits recorded along with the outcome of these visits. These showed a continuous monitoring of the health of service user’s. Employment information held for staff was well organised with all the required checks in place. Staff supervision is taking place and staff training is well Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 6 documented along with on going training needs being identified. This shows that the home is committed to ensuring that staff are well supported and trained. This protects the vulnerable service users living in the home. The annual holiday has been planned for 4 of the service users. The 2 remaining service users are to have ‘day trips’ organised as this meets their needs more appropriately. Advocacy services are provided by ‘Havcare’ for all service users in the home. There is also information in the home about ‘People First’ another advocacy group. There is a mix of gender within the staff group, this brings different qualities and outlooks to the care of the 6 male service user’s living at the home. What has improved since the last inspection? What they could do better: Although skill maintenance is undertaken on an individual basis there is no recording format to show if these skills are being maintained. There are no goals set for further development either. However, the manager stated that further progress and development of new skills would be set on very long term time scales and would vary from service user to service user. This would be based on their needs and individual ability and interest showed towards any skill either old or new, with an appropriate timescale being used. If this is the case and no further development or progress can be made at this time then this should be recorded in the ‘Person Centred Plan’. For one service user who has a ‘baby alarm’ being used to monitor any seizures, an ‘infringement of rights’ form must be completed. This alarm is in use as the Epileptic seizure monitor is not working appropriately despite input from the specialist team. Records of meal choices were inspected and it was observed that when a ‘take away’ meal is provided that the record of the actual meal provided is not recorded. This must be addressed to enable the home to evidence what each service user ate on that occasion. Medication recording needs to be tightened up for the application of prescribed creams and lotions, and also the recording of the amount of mediation prescribed to be administered ‘when necessary’. The amount of tablets held by the home at any one time, (Diazepam 5mgs) must be recorded on the Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 7 medication administration sheet and carried forward month by month to show a clear audit trail of this medication received by the home. A slight odour of stale urine was evident on the stairs and upstairs landing this carpet requires a deep clean. Also on this landing a drop leaf table was restricting access to 2 fire extinguishers, this table must be removed and stored elsewhere. One bedroom requires decorating. However a second bedroom was already identified in the ongoing programme of maintenance. The lounge carpet is stained and required a deep clean, if the stains cannot be removed then this carpet will require replacing. 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. Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5 These standards are well managed with the information being readily available. The homes documentation assists relatives and service users to make an informed choice about the service the home will provide. It also ensures that prospective service users’ needs can be met by the home prior to any planned admission. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide these are both written and pictorial and they enable service users to know the service the home is going to provide. However the dependency level of the current service user is such that some do not show an interest in wanting to understand the information. Service user’s individual needs, likes and dislikes are recorded on a ‘Person Centred Plan’. Service user’s would be able to have little input into the completion of these plans due to their high needs and information required would have come from relatives and past history of the service user. In discussion with the manager it was stated that prospective service users would be able to visit the home before they moved in permanently. Short visits would take place for a hour or so then these would be extended to a meal at the home, a day visit and overnight stays, then weekend stays. This is to ensure that the proposed service user’s needs can be met and the person ‘fits Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 10 in’ with the current service users already living at the home. At present there are no vacancies. A copy of the licence agreement (contract) (both written and pictorial) was observed to be held on service users files. Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 and 10 Service users needs are well met and documented. However the home should record skills maintenance to unsure these skills are not lost. Where service users abilities do not enable them to progress further, then this should be recorded. EVIDENCE: Due to the service user’s in this home having high needs, although they all have ‘Person Centred Plans’ they are unable to make decisions about the care that is provided for them, or understand the information held about them. Risk assessments are updated and behavioural monitoring takes place with identified problems recorded and guidance given to staff on how to manage such situations. Staff support service users to make choices within their limitations about how they spend their time and the activities that take place within and outside the home. From discussion with the manager, future goals would be set based on their needs, individual abilities and the interest shown towards any new skills, or the maintenance of existing skills. However it should be recorded in the Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 12 ‘Person Centred Plan’ if no further development of skills is likely to be undertaken. Entries in the service user’s daily diaries evidence how they have spent their day, but there is no set monitoring sheet to show whether they are maintaining skills. A system for this should be put into place. Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 14, 16 and 17. Standard 13 will be inspected at further inspections. These standards are well met within the restrictions that the high needs of the service users accommodated have. Service users are encouraged to participate in most areas of daily life, however this is only far as their abilities will allow. EVIDENCE: From discussion with the manager it was established that service users are asked what meals they would like for the coming week, each Sunday. Each service user’s choice or known likes and dislikes are taken into consideration when the menu is being drawn up. The record of meal choices was inspected. It was observed that on one day the record stated ‘take away’, however the home has to be able to show that service user are having a balanced diet therefore the actual choices service user make when a take away meal is provided should be recorded (fish and chips, Chinese meal, Curry meal, pizza and so on). Service users participate in activities suitable to individuals. A daily chart records the activities that they are to take within each week. A record is kept Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 14 of the activities undertaken. For one service user the activities sheet was not completed. Activities should be recorded on the day they are undertaken to unsure nothing is missed from the record, (a scrap of paper with entries written on it, but not dated was in the file however this does not evidence what has taken place), this must be addressed. House meetings take place approximately every 3 months and relatives and staff and service users get together to discuss the running of the home and anything that they would like to do. The last meeting took place on the 7/6/05. Minutes are kept of these meetings. Relatives visiting the home at the time of the inspection told the inspector that ‘our son is well cared for in every respect’ and that ‘we’re kept informed of any changes in his health’, ‘he is always kept clean and well dressed’. ‘We have no complaints or concerns about the home’. It was found that links with clubs are being kept up with one service user visiting another borough to continue attending a club he enjoys (Gateway in Thurrock). This is seen as good practice. Day centres are provided for two service users (one attends Monday – Friday, another day centre is attends 2 days a week) Life skills are taught at these centres. For a further service user a musical work shop is provided. A holiday is booked for July when 4 service user’s will visit Sutton–by-Dover. For the 2 other service user’s day trips out were said to be better suited to their needs. The home has a record of ‘infringement of rights’ and these are completed when an activity or outing cannot take place. However another infringement of rights that is not documented is the use of a ‘baby alarm’ this is in use as the epileptic seizure monitor designed to raise the alarm when a service user has a seizure does not appear to be working properly. The home must record the use of this ‘baby alarm’ as an infringement of the service users rights, (although this is being used to enable staff to respond quickly to any seizure that takes place and is necessary at the present time). Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Health care needs are well documented. Staff attend to any personal hygiene needs for all service user’s and are meeting the needs of the service users they care for. However the home must improve medication practices. EVIDENCE: Staff were seen to assist service users with respect when assisting them. All service users were well presented on the morning of the unannounced inspection. Interaction between the inspector and the service users’ was limited due to them being unsettled by people they do not know or having no speech. The manager stated that one service user is able to use limited Makaton signs mixed with their own ‘signing’ which staff readily acknowledged and understood. Some use their behaviours and physical prompts to make their needs known and communicate with staff in this way. This was observed by the inspector. The home has a key worker system with staff taking a particular care in relation to their identified service user. This appears to operate well, as relatives in discussion with the inspector were aware they could speak to the designated key worker to find out specific information when required. Health care needs are well documented with referrals to specialist health care professionals. The outcome of referrals was also well documented. The home is Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 16 also supported by a specialist nurse for people with learning disabilities who will give advice and support as necessary. Medication recording and medication held in the home for administration were inspected. It was observed that some applications of creams, or lotions used for bathing, that the medication administration sheet is not signed by agency staff. The inspector was informed that it was Outlook Care’s policy that staff who have not undertaken the medication training and assessment do not give or sign for medication. However the applying of a topical cream or lotion is different, therefore the agency staff/or Outlook Care’s staff should sign to say they have applied the creams/lotions as prescribed. When the daily diaries were checked in conjunction with the dates not signed on the medication administration sheets, the daily diaries did not have a record of the creams or lotions being applied or used in bathing. Any prescribed cream/lotion must be appropriately signed for by the person applying them. With the present situation the home cannot evidence that these creams and lotions have been used in line with the prescribing instructions. Medication for one service user which is prescribed to be administered ‘when necessary’ did not record the amount of tablets (Diazepam 5mgs 24 tablets held on 17/6/05) in stock. The medication administration sheet must show how many ‘when necessary’ medications are held in stock and the number of tablets must be brought forward each month and be recorded on the medication administration sheet to enable the home to show a clear audit trail of all medication held in the home. All other medication was appropriately signed for and administered as per the medication administration sheets. Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22. Standard 23 will be inspected at further inspections. Complaints were documented and evidenced that action is being taken to address concerns/complaints raised. EVIDENCE: Complaints were well documented with the action taken recorded to address any complaint raised and the outcome of the investigation also recorded. However the home must record whether the complainant is satisfied with the outcome of the complaint investigation. Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 30. Standard 29 does not apply to any of the current service users. The majority of the home was clean and well maintained. However some areas required attention. EVIDENCE: The majority of the home was clean and well maintained. Bedrooms were full of personal possessions that made them homely and individual. The stairwell and landing leading to the upstairs floor had a slight smell of stale urine. The house keeper said that she ‘spot cleans’ any particular areas. However this accident causing the odour has gone unnoticed and the carpet requires a deep clean. One service users room requires decorating (C’s room) another was said to be already planned for re decoration (B’s room). The lounge carpet is stained and dirty this requires a deep clean. If the staining cannot be removed then this carpet will require replacing. Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36 were inspected. The service users are supported and protected by the staffing levels and the recruitment and selection processes. These standards are well managed. EVIDENCE: On the day of the unannounced inspection staff were clear about what was expected of them and went about their duties in a professional manner. The recruitment and selection processes of the home are such that no staff commence duties without 2 written references and a CRB disclosure being returned and deemed suitable. All new staff have to complete an induction programme. A new member of staff (employed as agency bank staff) was undertaking this on the day of the inspection, this is a one day induction programme for agency bank staff. There is a staff appraisal at the 3 month probationary period and then again at 6 months and an annual appraisal is undertaken. The manager has made arrangements for extra staff hours to be provided on Tuesdays, Wednesdays, Fridays, Saturdays and Sundays when activities are to take place. This is seen as good practice. Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 20 Staff training was well documented and training certificates were held on staff files. From a random selection of staff files it was observed that training ranged from Autism, Epilepsy, positive behaviour, negotiating skills, NVQ levels 2 & 3, medication procedures (Midas), manual handling, food and hygiene, mental health and learning disabilities, abuse, diversity and cultural needs, health and safety, control of substances hazardous to health, and fire training. From a random selection of staff files it was observed that formal written supervision sessions are taking place with staff. Records showed dates when supervision had taken place on 2/12/04, 13/2/05, 13/4/04, 21/4/05 and the 16/5/05. Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 42. Standard 39 will be insepcted at further insepctions. The home is well run by a manager that places the needs of the service users above other constraints he has to work within. Despite many areas requiring his attention on the day of the unannounced inspection these were dealt with efficiently. EVIDENCE: The manager is suitably qualified and is registered by the Commission to carry out the role of manager. There are no outstanding requirements from the last inspection and there are very few new requirements made at this inspection. Health and safety was well managed with fire drills taking place, the last recorded drill was documented as being held on 5/6/05 the fire alarm and emergency lighting was service on 20/5/05 and the fire extinguishers received their annual check on the 21/3/05. Weekly fire alarm tests are taking place and these are also recorded. The fire risk assessment of the home was completed on 14/9/04. Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 22 The 5 year electrical safety check was dated 14/6/04 and the annual portable appliance test was dated 24/12/04. The annual Gas safety certificate is dated 20/10/04. The homes public liability insurance certificate is current with a renewal date of 31/3/06. Accidents are well documented with body maps to identify any injury. One area that was found to be failing was on the landing at the top of the stairs a large drop leaf table was restricting access to 2 fire extinguishers. This table must be removed as a matter of urgency. Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 3 3 2 N/A 2 Standard No 11 12 13 14 15 16 17 x 3 3 3 x 2 2 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beauty Way Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 2 x v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 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 YA6 Regulation 12(1b) Requirement Have a system of recording skills mainteanence and goal setting for service users. Where no further goals are deemed achievable this should be recorded in the Person Centred Plan. Complete an infiringment of rights form due to the baby alarm being used to monitor any epilectice seizures. Record the actual meal eaten when a Take awaymeal is provided. Medication prescribedas when necessary (Diazepam 5mgs) must have the number of tablets held by the home recorded on the current medication administration record and carried forward each month to enable the home to show a clear audit trail of medication received into the home. All applications of prescribed creams and lotions must be signed as being applied/used on the medication record sheet to enable the home to evidence that thssi has been applied in line with prescribing Timescale for action 30/08/05 2. YA16 15(1) 30/06/05 3. 4. YA17 YA20 17(2) Sch4(12) 13(3) 17/06/05 14/06/05 5. YA20 13(3) 14/06/05 Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 25 instructions.. 6. 7. YA26 YA28 Decorate the bedroom belonging to (C). 23(2d) Deep clean the lounge carpet. If the staining cannot be removed then thsis carpet will require replacing. 23(2d) Deep clean the landing and stair carpets (due to a slight odour of urine). 23(4a,3a(i Remove the drop leaf table that i) is blocking the access to 2 fire extinguishers on the landing at the top of the stairs. 23(2d) 30/09/05 15/07/05 8. 9. YA28 YA42 15/07/05 14/06/05 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 Good Practice Recommendations Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU National Enquiry Line: 0845 015 0120 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 Beauty Way v233912 g55_s0000027835_beauly way_v233912_170605_stage 4.doc Version 1.30 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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