Inspection on 15/08/06 for Belvidere Park, 6

This inspection was carried out on 15th August 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Belvidere Park, 6 23/01/06

Belvidere Park, 6 06/07/05

Belvidere Park, 6 02/03/05

Belvidere Park, 6 02/06/04

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 Belvidere Park, 6 6 Belvidere Park Crosby Liverpool Merseyside L23 0SP Lead Inspector Mrs Janet Marshall Unannounced Inspection 15th August 2006 10:00 Belvidere Park, 6 DS0000005248.V300889.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 Belvidere Park, 6 DS0000005248.V300889.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. Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belvidere Park, 6 Address 6 Belvidere Park Crosby Liverpool Merseyside L23 0SP 0151 284 0023 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) Expect Limited Mr Michael James Geddes Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 3 LD. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 23rd January 2006 Date of last inspection Brief Description of the Service: 6 Belvidere Park is a care home registered for three people with a learning disability. The registered provider for this home is Expect, formerly known as Sefton Support Services. This organisation is in the voluntary sector and is a registered charity. The property is owned by Liverpool Housing Trust. The home is located in a residential area in Crosby. The house is in keeping with other properties in the area and is indistinguishable as a residential care home. The home is within walking distance of local shops and Crosby village shopping centre is near by. The home is a large five bed roomed house with two reception rooms and good sized gardens. The home provides two staff 24 hours per day and operates on the principle of ordinary community living. Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection visit (site visit) at the home this inspection year. The inspection was unannounced and took place for a total of 6 hours. The Commission considers 22 standards for Care Homes for Adults (18-65) as Key Standards, which have to be inspected at least once in a 12-month period. All Key standards, which are identified in bold within the main body of the report, were inspected during this inspection. During the site visit the requirements and recommendations from the last inspection report were discussed and checked with the manager. A number of them have been met. Those that have not have been raised again as part of this report as well as a number of requirements identified during this visit. A partial tour of the home was conducted. Care records and other required records were inspected, they included a selection of resident’s care plans, daily diaries, medical notes, and medication and associated records, staff rotas and certificates of health and safety checks. Two residents were “case tracked”. Case tracking means that the Inspector concentrates on the care given and experiences of one or more residents to get an idea of what is like to live at the home and how that person’s needs are being met. Prior to the site visit the commission sent out to the home a pre - inspection questionnaire. The commission did not receive the document. The manager and two members of staff were interviewed during the site visit. The nature of the disability of the residents is such that it was not always possible to obtain direct views about their experiences, however, non-verbal communication and general observations took place throughout the visit and have been used towards measuring standards for the purpose of this report. What the service does well: There was a warm and friendly atmosphere at the home. Discussions & observations showed that staff have a positive attitude towards the residents and their disabilities. Residents are supported to take responsible risks and make choices and decisions as part of an independent lifestyle. The health care needs of residents are well met which ensures their physical well being. The service provides a good level of training for staff to ensure that they are competent and qualified to meet resident’s needs. Procedures and practices carried out in the home ensure that residents live in a comfortable, safe and clean environment. Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Belvidere Park, 6 DS0000005248.V300889.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 Belvidere Park, 6 DS0000005248.V300889.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Processes are in place to ensure that an individual chooses a home that will meet his/her needs. EVIDENCE: There have been no new residents admitted to the home in the last twelve months. Previous inspections have evidenced that a full and proper assessment has been carried out by appropriate people for each person before they were admitted to the home. Available at the home were a number of policies and procedures relating to the admission of new residents they included, emergency admissions, referral and admission and introductory and trial periods of residency. There was also a policy on meeting resident’s needs. Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 9 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 the following standard(s): 6, 7 & 9 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Residents are supported to live an independent lifestyle. EVIDENCE: A care plan was in place for each person. Care plans covered all aspects of the person’s personal and social support and healthcare needs. Case tracking showed that the information included in care plans reflected the persons assessed and changing needs. Records showed that care plans are regularly reviewed and updated with the involvement of the resident, key worker and manager. All the residents that live at the home have complex learning disabilities and find verbal communication difficult because of these residents were unable to clearly express their views, opinions and experiences about the service. Residents however are able to communicate day-to-day choices and decisions in a number of ways such as sounds, body language and gestures. Care plans provided detailed information about each persons preferred communication methods. Communication dictionaries were available for individuals, they identified to staff the residents preferred and most effective way of communicating. This is a very good tool used by staff so that they can Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 10 communicate non-verbally with residents. Staff were observed communicating effectively with residents using their preferred communication styles. During discussion and on observation staff showed that they respect resident’s rights to make decisions. Because of limitations residents are not able to make choices and decisions about many aspects of their lives therefore staff provide them with assistance and communication support so that they can make choices and decisions. Information about choices and decisions that are made for people and the reason why was clearly recorded in care plans. There are certain limitations placed upon residents to prevent them and others from abuse or harm. Limitations include access to parts of the home and the community, the management of finances, medication administration and involvement in activities. Details of limitations were recorded in individual plans of care. Case tracking showed that these decisions were made in the persons best interests, consistent with their assessed needs. Where a resident is involved in an activity, which may present a risk to themselves or others then a risk assessment, has been carried out. Risk assessments that were examined included information on the action that needs to be taken to minimise the identified risk. Risk assessments covered areas such as health and personal care, behaviour, environment, and relationships. The risk assessments viewed were detailed and comprehensive and showed that they are monitored on a monthly basis and are regularly reviewed. A risk taking and risk management policy were in place at the home. Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 12, 13, 15, 16 & 17 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Residents are given more opportunities to live fulfilling lives outside the home, however, residents do not always enjoy mealtimes. EVIDENCE: Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 12 Each of the residents has a development plan, which identifies how to support them to develop their skills, and identifies future goals, which the they support to achieve. Residents are encouraged to make choices and each of them has a communication dictionary. This assists staff in understanding the non-verbal communication used by the residents. Staff were observed communicating effectively with each resident. Residents were seen making choices and decisions, which were understood and responded to by staff. Records at the last inspection showed that two residents were not taking part in regular community based leisure activities. A requirement was given for this as part of the last inspection report. Daily records for each resident were examined during this visit and showed that since the last inspection all residents have accessed the community on a regular basis. The records checked covered the past six weeks. Activities in the community included trips to the park, cinema, local shops, cafes and pubs. A requirement was given as part of the last inspection for the manager to review all menus and ensure that the residents are offered a healthy, well balanced diet including fresh foods. Records of menus were examined, these showed that food eaten by residents is healthier, well balanced and more varied in content. Food stores were examined, they were well stocked with a variety of fresh, frozen and tinned items. Due to limitations residents are not involved in the preparation of food, all meals are prepared by staff. Care plans provide staff with details of residents likes and dislikes with regard to food. During discussion a member of staff confirmed their knowledge of a residents food preferences, the information given was recorded in the persons care plan. Each resident needs some level of assistance at mealtime. One resident requires full assistance whilst others require prompting and assistance with cutting food up. The home does not have a separate dining room. A small dining table is situated in the kitchen. The midday meal was observed. Staff were observed assisting residents in a patient and unrushed way. All residents were sat down together for lunch at the small table in the kitchen. The kitchen appeared cramped and noisy, a member of staff reported one resident is often put off by this and leaves the table before finishing their food. It was felt by staff that the resident would benefit from eating alone. Additional dining space must be provided for residents. These issues were discussed with the manager. Mealtime arrangements must be reviewed so that they are flexible to suit each person’s individual needs. Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 18, 19 & 20 The quality outcome in this area is adequate. This judgement has been made using available evidence including a site visit. Residents are provided with appropriate personal and healthcare support, however residents are not fully protected by the homes procedures for dealing with medication. EVIDENCE: All residents require assistance with personal care including advice, guidance & support. Care plans that were examined had a detailed and agreed routine, which showed a great deal of staff input & guidance and the importance of the routine for the residents. Regular reviews allow staff to address any issues or changes to care that may be necessary. A selection of healthcare records was seen and was detailed and satisfactory. During interviews staff were asked about the way that they support residents with personal and healthcare. They provided the following responses: “It is important to respect residents privacy and dignity, I always do this when helping them with personal care, for example I make sure that doors are shut and I always knock before entering a bathroom or residents bedroom” “I talk to residents about the help I am going to give them before I do it” “I always ask what they would like and give choices” “It is important to make sure that the person is happy and relaxed” Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 14 Information on the needs of the residents with their personal care was recorded in their care plan. It was reported that there are no restrictions on the times that residents are supported with having a bath or going to bed etc. and the residents are reported to communicate when they want support with these tasks. Each of the residents has a care plan relating to their health care needs. This includes target and actual dates for health checks and these were up to date. There was evidence in residents files that relevant health professionals are referred to as appropriate. Records indicated that the residents are regularly supported to attend health related appointments and that staff have followed up concerns appropriately. Where a resident requires support with a specific health condition there is information on the condition and guidelines are in place for how to support the resident. During interview a member of staff said, “ I report and record all changes to residents health and personal care, it is important to do this so that they receive the care that they need”. As part of the last inspection report a number of requirements were given in relation to dealing with medication. That was because medication stock records were incorrect and some medication administration records were not fully complete. The home has a medication policy. None of the residents administer their own medication and it was reported that it is unlikely that they will in the future. Records are maintained of medication received and administered and there is a system for stock checking medication. The manager explained that she was in the process of carrying out an investigation because medication stock and records did not balance. The manager must ensure that staff that handle medication check stock and complete records accurately and that she audits the records on a regular basis to ensure that they are accurate. Guidelines for the administration of as required medication are in place. Medication administration records for residents were examined during the site visit and found to be accurate. In response to a requirement given as part of the last inspection staff have recently commenced medication training. To ensure the health and safety of resident’s staff must not handle medication unless they have completed the required training. Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 22 & 23 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Appropriate procedures are in place for responding to concerns and complaints and for ensuring that residents are safe from abuse or neglect. EVIDENCE: There has been no complaints made to the Commission for Social Care and Inspection about the home since the last inspection. There were no recorded complaints at the home. A complaints procedure was viewed at the home. It included detailed information about the stages and timescales involved in the process so that people are clear about how to make a complaint and the processes involved. A comment, complaints and suggestions notice is also available in the home along with a complaints leaflet. Discussion with staff showed that they are confident about telling somebody if they were uphappy. A member of staff said, “I know about the homes complaints procedures and would tell somebody if I was unhappy about something”. A copy of the local authorities protection of vulnerable adults procedure was available at the home. The manager confirmed that all staff have undertaken protection of vulnerable adults training. Certificates of attendance confirmed this. During discussion staff showed a good awareness of what to do if they suspected abuse was taking place or if an allegation of abuse was reported to them. A member of staff said, “I would always report abuse of any kind”. The home has a protection of service users policy and a whistle blowing policy. There is also a policy on physical intervention and aggression towards staff. Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 16 All accidents or injuries are recorded and there is a procedure in place for reporting these. The home has a policy on the management of service user’s money and financial affairs. There was evidence that each resident has their own bank account, which they can easily access when they choose. Resident’s money and budgets sheets that were examined were found to be in good order. Belvidere Park, 6 DS0000005248.V300889.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. The home is clean, bright and spacious providing a pleasant environment for residents, however, a number of improvements are required to ensure their complete comfort and safety. EVIDENCE: The home was clean and tidy on the day of the site visit. The home is located in a popular residential area of Crosby. It is close to public transport links and community services and facilities. Relationships with neighbours were reported as being good. A tour of the home took place on the day of the visit. This showed that most parts of the home were generally well maintained with some minor improvements required. These are described further on in this part of the report. All parts of the home were clean, tidy and hygienic. There was a warm and friendly atmosphere at the home at all times during the visit. Support staff are responsible for the general day-to-day cleaning of all areas of the home. The homes health and safety file included information about the use and storage of hazardous substances. There was sufficient cleaning equipment and Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 18 products available at the home. A requirement was given as part of the last inspection report for all hazardous substances to be stored safely observation showed that at this site visit they were stored and used in accordance with the homes policies and procedures. All residents’ bedrooms were viewed on the day of the visit. Two of them were nicely decorated and furnished to a good standard. One resident’s room has not yet been redecorated, this was a requirement as part of the last inspection report. The manager confirmed that the room is scheduled to be decorated in the near future. The room must be redecorated to a satisfactory standard to ensure the comfort and dignity of the resident. All rooms were personalised and included items such as music centres, televisions, lights and pictures. At intervals throughout the visit residents were seen watching TV and relaxing in the lounge and their own rooms. The kitchen units and worktops are dated and showed signs of wear and tear. A large area of the kitchen ceiling was damaged. It is recommended that refurbishment of the kitchen takes place so improving the environment for the residents. Since the last inspection carpets have been replaced in two bedrooms and a new dryer has been purchased. The heating system, front and back gates have been repaired and all interior windows have been cleaned. It was recommended as part of the last inspection report for the outside of the home to be repainted, this has not yet been done and lets the overall appearance of the home down. Belvidere Park, 6 DS0000005248.V300889.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. The homes recruitment and training procedures ensure that the staff team have the qualities and qualifications that are required to meet the needs of the residents. EVIDENCE: Recruitment and selection policies and procedures were available at the home. A selection of staff files was examined. They included three written references, evidence of satisfactory criminal record bureau checks, interview notes and record of training and development. None of the files examined contained a copy of a completed application form. The manager reported that they are kept at head office. During discussion staff confirmed that at the start of their employment they were given a copy of the homes terms and conditions. Records examined at the home and discussion with the manager and staff evidenced that staff at the home have undertaken the required mandatory training in the last twelve months, including protection of vulnerable adults first aid, manual handling, health and safety, food hygiene and administration of medication, epilepsy awareness and stress awareness. Other training undertaken includes the role of the support worker and induction training. During interview a member of staff said that they are happy with the level of training. Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 20 Staff who were interviewed confirmed that they have commenced or completed an national vocational qualification in care Level 2 or above. Individual training and development plans were available for each member of staff. The plans detailed both passed and future training. Records showed that training is linked to the aims of the home and residents needs. Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Residents benefit from a manager who is qualified and experienced, however this is undermined because the manager has not yet applied to the Commission to be registered manager of the home. EVIDENCE: A new manager has been appointed at the home since the previous inspection. The manager who has national vocational qualification level 4 in care was previously the registered manager of a similar service also operated by Expect. The manager confirmed that she has not yet made an application to the commission to be registered manager. This manager must make an application to the Commission to be registered manager of the home. A requirement was given as part of the last inspection report for the quality assurance process at the home to be developed to ensure that the service users and their representatives are given the opportunity to feedback on the service. Since the last inspection questionnaires have been given out to residents and their representatives. A number of completed questionnaires Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 22 were viewed at the home. Also as part of the homes quality assurance process and in accordance with Regulation 26 of the Care Homes Regulations 2001 Amended (2004), a representative for the home visits the premises monthly. They interview residents and staff, check records and inspect the environment. It is important that this is done to check the standard of care in the home. Following the visit a report detailing the visit is written and a copy is sent to the Commission. Records show that the visits and reports are being carried out each month as required. Records that were examined showed that staff have received training in areas of health and safety including moving and handling, fire safety, first aid, food hygiene and health and safety. The home has a number of policies and procedures which aim to ensure the health and safety of service users and staff and these include policies on health and safety, first aid, fire safety, food safety, medication, control of infection. Cleaning products, which were not being stored correctly at the last inspection, were seen at this inspection to be stored safely. There was evidence at the home that equipment safety checks and gas and electricity certificates were all up to date. Risks assessments were in place in relation to the environment and safe working practices. Records showed that since the last inspection risk assessments have been updated to include changes to the environment. A requirement was given as part of the last inspection report for fire safety checks to be carried out regularly. This was because records showed that the testing of fire alarms was not being carried out at the required intervals. Fire records that were examined at this site visit showed that the system has been regularly tested and is in good working order. During interviews two members of staff confirmed that regular testing of the fire alarms take place. Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 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 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 2 2 X 3 X X 3 X Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 24 Yes 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 YA37 Regulation 8 Requirement The registered person must ensure an application for registration of the manager is made to the Commission. Medication stock and records must be maintained accurately at all times. All staff must be provided with medication training. Mealtime arrangements must be reviewed. One of the service user’s bedrooms must be redecorated. Timescale for action 22/10/06 2. YA20 13 (2) 22/09/06 3. 4. 5. YA20 YA17 YA25 13 (2) 12(3) 23(2)(g) 23 (2) (d) 22/10/06 22/10/06 22/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations Information should be produced in appropriate formats whenever possible. DS0000005248.V300889.R01.S.doc Version 5.2 Page 25 Belvidere Park, 6 2. YA24 The exterior presentation of the home needs attention. Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Belvidere Park, 6 DS0000005248.V300889.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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