Inspection on 30/01/08 for Bedford Road, 153

This inspection was carried out on 30th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bedford Road, 153 23/11/06

Bedford Road, 153 19/01/06

Bedford Road, 153 21/09/05

Bedford Road, 153 13/01/05

Bedford Road, 153 22/04/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Bedford Road, 153 153 Bedford Road Bootle Liverpool Merseyside L20 2DR Lead Inspector Diane Sharrock Key Unannounced Inspection 30th January 2008 1:30 Bedford Road, 153 DS0000005236.V348012.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 Bedford Road, 153 DS0000005236.V348012.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. Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bedford Road, 153 Address 153 Bedford Road Bootle Liverpool Merseyside L20 2DR 0151 933 5397 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) bedford153@autisminitiatives.org www.peterhouseschool.org Autism Initiatives Mrs Elizabeth Murtagh Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 3 LD Date of last inspection 23rd November 2006 Brief Description of the Service: 153 Bedford Road is a four bedroom terraced house situated in a residential area of Bootle. The property is registered as a small care home to provide accommodation for three men who have learning disabilities. The home is operated by Autism Initiatives an organisation that provide support for people with autism. The home provides staff 24 hours a day to provide support for the residents who live there. The overall philosophy being to maximise ordinary living and to promote independence of the residents in all aspects of their daily life both at home and in the community. The Registered manager is Bea Murtagh. Information about the fees for the home have been requested from the manager. The fees are from £1199.50 per week to £ 1639.91 Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality Rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We visited the home unannounced on the 30th January 2008 where time was spent reading records and looking at the building and meeting people at the home. A system called, ‘case tracking’ was used as part of the visit. This involves looking at the support a person gets including their care plans, medication, money and bedroom and living area. Case tracking was used to look at life at Bedford Road for one of the people living there. We also spent time meeting with people who live there and with staff about how they meet the person’s needs and choices. Discussions took place with three staff and the manager. We received one comment card from one resident and four cards from staff and their views are included into this report. An easy to read summary of this report is available. If you would like to see a copy please ask the staff working at Bedford Road. The manager contributed to the inspection process by completing a selfassessment form, which has helped give us some information about the home. The information gathered from the site visit along with any information about the home that we have received since the last key inspection, has been used to write this report. What the service does well: Support is provided to the people living at Bedford Road to make their own daily decisions and spend their time in activities that they enjoy, including going on an annual holiday The registered manager has been in post for many years and continues to provide an effective leadership role. Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Full feedback was given to the staff in charge in charge during and on conclusion of this visit. Some areas were noted to need action taken and further evidence to be in place to meet other standards and regulations Sometimes there are not enough staff at Bedford Road which stops some people going out and doing what they like. The company must produce an action plan regarding the recruitment and selection of staff stating what they will do to make sure they have enough permanent staff to give the stability and support to enhance the resident’s quality of life. Those residents who are not being supported currently as requested in their support plans must have updated care management reviews so that discussions can take place regarding changes to the plan and actions can be agreed to improve on the access to support. Staffing levels must be kept under review in order to make sure that staffing levels are appropriate to the needs of the residents. These reviews should be included with staff and residents and their opinions should be included in the reviews. Care plan/support plans should be regularly reviewed and actions taken to increase the resident’s choices and accessibility to the right support. A training plan should be put together which looks at the individual support of everyone at Bedford Road including agency and bank staff. This would help to ensure that all staff have the skills to meet peoples support needs and that they are up to date with current good practice and make sure residents are safe at all times. Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 7 All staff must have access to at least 5 days paid training per year and be able to safely and adequately support the residents and be up to date in basic training and also include current updates in eg the Mental Capacity Act. An updated development plan should be produced and shared with residents; staff and relatives to show what plans are taking place regarding their home including the decoration and maintenance of the home. The home must have a complete file of essential policies, which are necessary to assist with good practice in updated procedures. The responsible person must make sure that all regulation 26 visits are carried out monthly and reports produced to show there are regular company checks on the standard of living offered in the home. A working fax must always be available at the home to make sure there is an effective means of communication in the home at all times, especially if the phone lines were ever effected. 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. Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate information is provided prior to residents moving into the home which help to ensure that prospective residents needs are fully assessed so that they can be sure of meeting the person’s needs. EVIDENCE: Since the last key inspection no new residents have moved into Bedford Road. There are polices and procedures in place to ensure that sufficient information is obtained about the person, including an assessment of their needs, to ensure that Bedford Road can meet their choices and support needs. Bedford Road, 153 DS0000005236.V348012.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 judgement has been made using available evidence including a visit to this service. People’s individual needs and choices are recognised within the service, although they are sometimes restricted by staffing levels. EVIDENCE: Detailed individual care/support plans were available for each of the residents. One care/support plan was looked at in detail. The plans were well presented and covered all aspects of the person’s personal and social support and healthcare needs and were able to demonstrate they can meet the diverse needs of residents at the home including, communication and behaviour management. Some of the plans had not been updated since September 07 and it was acknowledged that some parts of the plans regarding social support had not always been carried out for various reasons mainly due to staffing issues at the home. Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 11 Staff explained that 2 residents had not had care manager reviews recently. During discussion it was felt they would benefit from updated reviews so that it could be acknowledged their support plans were not always being carried out due to various staffing issues and staff being utilised to support one resident. The opportunity for residents to make decisions and their needs known relies to some extent on the staff team understanding and responding to their agreed forms of communication. This was observed during this visit and care plans reflected the staffs understanding and knowledge and rapport with the residents. We received one comment cards from a resident prior to our visit which was positive and staff helped support the person in making their views known. We met the residents present at the home one person was able to talk about what they had done that day and was looking forward to their tea. We looked at residents financial records, which were well kept, accurate and in good order. Records showed that each resident has a bank account in their own name. The manager explained the arrangements that were taking place with the management of residents funds and the company were in the process of setting up a different bank account were all residents monies will be managed at head office. There was no evidence of any discussions or inclusion of such changes with any of the residents, there were no assessments around capacity or evidence to show it was in residents best interest or that it would provide any more choices or benefits to their personal monies being managed in that way. Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12/13/15/16/17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff provide support to residents to meet their social needs. EVIDENCE: Staff were observed to have a good rapport with residents and were observed to assist residents in various choices. Resident’s rights and choices were seen to be respected especially in the preparation of tea and in respecting each persons privacy when they came home from the centre. We chatted to staff and looked at records that showed that each of the residents attend day care for part of the week. On other days they are supported by staff to take part in a variety of tasks and activities both in and outside the home. The risk assessments have been produced to support residents to overcome difficulties and engage in activities in a safe manner. Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 13 Day time activities include, cleaning and tidying the home, walks, shopping and lunches out. It was noted that some residents had not being going out as much as usual especially in the evenings. Staff explained various staffing issues that had occurred over the previous months were they had to use bank staff. We received four staff comment cards which were mainly positive about working at the home but there were various comments about the staffing levels and working lower than the usual numbers due to staff absences. Some staff gave suggestions that they would like to see more getting done for the residents and be able to go out more. The manager has now recruited 2 permanent staff and hopes this will help the staffing issues and give better stability and support to the residents support plans. Everyone can go on an annual holiday if they choose. Staff talked about the last holidays. Staff said that the residents have enjoyed these holidays and they were looking forward to planning the next one. Staff explained that the residents pay for their own holiday. Discussion took place around the national minimum standards were its advised as good practice that the company should provide at least one holiday each year for all residents. In chatting to staff and looking at records they showed that staff support residents to maintain family links and friendships. Records evidenced that family and friends are always welcome. We watched staff supporting residents in the evening getting ready for the evening meal. They provided assistance and encouragement in a sensitive and flexible way. The kitchen was equipped with domestic style appliances and staff helped provide meals that residents personally chose. Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18/19/20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are supported by staff. EVIDENCE: The care plans and risk assessments provide the staff team with information about the most appropriate and safe way to support residents with their personal care needs. Care/support plans provided detailed information about the type and level of personal and healthcare support that each person requires. The persons preferred routines with regards to personal care were also available in good detail. Information was available in a way, which ensures each residents privacy, dignity and independence is met. There are no policies or guidance for staff regarding the companies responsibilities in maintaining and replacing equipment at the home and there was no guidance for staff regarding acting in the best interests of residents when purchasing equipment on their behalf, especially when they could not give staff permission to access their money and buy things. Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 15 The information given to us before we arrived at the home had not been fully completed and the manager acknowledged that she didn’t have a lot of standard policies and procedures which are needed to make sure everyone is kept up to date with good practice. The homes staff manages all of the residents medication needs including ordering, storing and administering. Medication was stored and recorded correctly, with clear records of medication received and given. This helps to reduce the risk of mistakes occurring and provides a clear audit trail to check people receive their medication correctly. Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22/23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the homes procedures for responding to concerns and complaints. EVIDENCE: We saw the complaints records during this inspection and there had been no recent complaints. These records showed that the company policy was being followed with the right record keeping in place. There has been no complaints received by the Commission about the home since the last inspection. The manager explains in her pre inspection information that they are looking at the complaints procedure but feels its complex for residents and would hope to eventually help support them with this procedure. The manager felt that over the last 12 months they have supported residents in being able to say, “no” more due to the plans and choices offered. The manager had a company-training brochure for 2008 giving details of all training on offer to help keep staff up to date in all necessary policies and procedures including complaints and abuse awareness. Bedford Road, 153 DS0000005236.V348012.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Bedford Road provides a comfortable environment for people to live in. EVIDENCE: The home is a terraced house in the residential area of Bootle, Merseyside. We saw a sample of areas throughout the home during our visit. The home was decorated and furnished to an adequate standard. We saw bedrooms which were personalised, were some people had various personal items to help them individualise their room. There was no maintenance, decoration or development plan to let people know when their home or bedroom would be redecorated. Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 18 A sample of maintenance certificates were seen which showed up to date checks as listed in the homes pre inspection questionnaire which helped show what actions were taken to keep the home safe to live in. The home is located close to shops, pubs and other community facilities including public transport links. . Bedford Road, 153 DS0000005236.V348012.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The people living at Bedford Road are adequately supported by staff however sometimes a lack of staffing can impact on residents’ lifestyle and choices. EVIDENCE: At the time of the visit there was one new support worker initially and the manager on duty then 2 staff came in later in the afternoon/early evening. At intervals throughout our visit staff were seen interacting well with residents. They were flexible and positive in their approach and appeared to have a good understanding of the needs of the residents. We chatted to staff who displayed a good knowledge of the people they support and their individual support methods and choices. Staff were observed to spend time talking with people as well as providing the more practical support that they required. Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 20 Staff comment card stated, they were mainly positive about working at the home but there were various comments about the staffing levels and working under the usual numbers due to staff absences. The manager was honest in explaining the difficulties they had endured regarding staffing levels and the effects this had had. She said they had to use bank staff for some time and had just recruited 2 full time staff, which she felt would improve on the previous situation. The company had an overall staff training development plan but this was quite basic and not dated. It gave no details on the individual staff needs or details of training being planned for the staff team at Bedford Road. We looked at Autism initiatives training brochure for 2008, which offered dates for staff for different training sessions including, “finance/Asperger/epilepsy/first aid/ fire safety/ food hygiene/ infection control, “etc. The brochure covered a diverse list of training necessary to keep staff up to date in supporting residents. The manager said it had been difficult to access the companies set training dates due to staffing issues but felt things would now get better due to the recent recruitment of new staff. The manager acknowledged the company had not yet arranged any training for the new mental capacity act, we discussed the need to look into this and arrange especially in supporting all of the men with decisions and choices eg finances and change of accounts. One staff member who works on the bank explained they had not had any induction training and would like more training provided. No information is given in the pre inspection questionnaire regarding whether staff are provided with induction, this section was left blank. No details are given in questions asking if staff have had training in food hygiene or if there is a staff development programme. There was no information given for the question on have all staff had recruitment checks. The manager has agreed to resubmit this form and to give updated information regarding training and recruitment checks in the home. We were unable to access the staff personal files as the manager had this information locked away. She also advised that some recruitment information was kept at head office. We were unable to check on safe recruitment practices and training needs and discussed how the manager could evidence that all necessary checks are in place to show residents are kept safe with good recruitment policies procedures, especially on checks kept at head office. Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 21 Approximately 8 staff have already achieved a National Vocational Qualification (NVQ) in care level 2 or above and one other person is working towards their qualification. This is a good amount of staff who have been supported in obtaining a care qualification necessary to support residents. Bedford Road, 153 DS0000005236.V348012.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is mainly well managed to the benefit of the residents and staff. EVIDENCE: The registered manager Mrs Bea Murtag. The manager has been at the home for many years and offers a great stability and rapport to all the residents and staff. The manager was asked to resend her pre inspection questionnaire (AQAA) with updated information about the home as it was only partially completed. The manager has agreed to resubmit this form and fill in all sections so the commission are given updated information about how the home is operating and managing. Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 23 The manager was seen to have an open and positive management approach and worked regularly as part of the team. As part of the homes quality assurance process and in accordance with Regulation 26 of the Care Homes Regulations a representative for the home visits the premises monthly. It is important that this is done to check the standard of care in the home. Records show that the visits and reports are not always carried out each month as required. Staff felt the last visit was in September 07 with no recent visits. Various points identified in this report show that the staff have been put under pressure for various reasons mainly to do with staffing levels. This point needs to be discussed within the company regarding how they should support homes in times of difficulty so that the service is not affected. The manager continues to organise regular staff meetings. This ensures that staff members have a regular forum to discuss issues that may affect the service provided to residents and the implementation of polices, procedures and practices within the home. Staff minutes were seen of recent meetings and showed details of various topics about the home. We looked at various files seen including polices and procedures, however the pre inspection questionnaire had a lot of blanks regarding whether they had a policy in place for eg, cosh, Infection control, accidents, access to files. Etc. The manager explained that various policies are not in place and accessible to everyone at the home. These policies are all necessary so that staff are kept up to date and informed of the right practices and procedures to be followed. Information provided in the pre-inspection questionnaire and examination of a selection of health and safety records showed that the required health and safety checks have been carried out on the environment, for example fire system checks, gas and electricity checks. This showed a good system for safely managing the home. Bedford Road, 153 DS0000005236.V348012.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 X 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 x 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 x LIFESTYLES Standard No Score 11 X 12 2 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 2 X X 3 x Bedford Road, 153 DS0000005236.V348012.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 Standard YA34 Regulation 19 1 schedule 2 Requirement All staff must have police checks and appropriate supervision. So that residents can be protected by good recruitment and selection policies and procedures. Staffing levels must be kept under review in order to make sure that staffing levels are appropriate to the needs of the residents. These reviews should include staff and residents opinions. Staff must show evidence of how they have covered any staff absences so that enough staff are in place to provide the right support for residents. 2) Timescale for action 16/03/08 2 YA35 18 1a 16/03/08 3 YA37 24 1) 4 YA39 26 The home must have a complete 16/03/08 file of essential policies, which are necessary to assist with good practice in updated procedures. As part of the homes quality 16/03/08 assurance process and in accordance with Regulation 26 of the Care Homes Regulations a representative for the home must visit the premises at least DS0000005236.V348012.R01.S.doc Version 5.2 Page 26 Bedford Road, 153 monthly. It is important that this is done to check the standard of care and support in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA7 Good Practice Recommendations The way in which money belonging to the people living at Bedford Road is managed must be reviewed and must take the resident and their representative’s opinions into account and shown to be managed in their best interest. To make sure that residents have enough choices and information to have their monies managed how they would want it to be. Financial policies and procedures must be clear and accurate and explain any financial outgoings eg, including purchasing of equipment, holidays. The company should be clear in making people aware of their legal responsibilities in providing the right care and equipment and upkeep of facilities at the home. Care plans should be reviewed and actions taken to increase the residents choices and accessibility to the right support. Staff must arrange updated care management reviews so that plans can be updated especially were they have been affected by staffing levels. To support and facilitate residents to access a variety of age and culturally appropriate activities on a regular basis and make sure staffing levels meet the resident’s needs and never restricts their daily living and quality of life. A training plan should be put together which looks at the individual support of everyone at Bedford Road including bank staff. This would help to ensure that staff have the skills to meet peoples support needs and that they are up to date with current good practice and make sure residents are safe at all times. Appropriate induction must be provided for all new staff working at Bedford Road including bank staff. All staff must have access to at least 5 days paid training per year and be able to safely and adequately support the DS0000005236.V348012.R01.S.doc Version 5.2 Page 27 2 YA6 3 YA12 4 YA32 Bedford Road, 153 5 YA34 6 YA39 residents and be up to date, in eg, basic training and look at including updates on the Mental Capacity Act. The company must produce an action plan regarding the recruitment and selection of staff stating what they will do to make sure they have enough permanent staff to give the stability and support to enhance the resident’s quality of life. The manager must look at reviewing all recruitment checks kept at both head office and at Bedford road and show they are up to date and show safe systems are in place before staff commence work at the home. A system for regularly reviewing the quality of the service must be implemented and reviewed. Residents, staff and relatives opinions must be taken into account regarding the development of their home. Any proposed developments or plans to change eg the management of resident’s finances must take the resident and their representative’s opinions into account. Opinions should be sought about the decoration, maintenance and holidays. Opinions should be sought on financial guidance and the responsibilities of making large purchases on behalf of residents, opinions must be sought on changes to staffing levels and the impact it has to each persons support plan. The company must provide effective equipment to assist with good communication at all times, a working fax must be provided to Bedford Road For the manager to resubmit her pre inspection questionnaire with all relevant sections completed to give updated and accurate information to the commissions regarding the management of the home. 7 8 YA37 YA37 Bedford Road, 153 DS0000005236.V348012.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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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