Inspection on 22/05/06 for Besford House

This inspection was carried out on 22nd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Besford House 10/06/08

Besford House 25/04/07

Besford House 27/01/06

Besford House 23/09/05

Besford House 08/12/04

Besford House 03/04/04

Besford House 27/09/03

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

CARE HOME ADULTS 18-65 Besford House 19 Besford Road Liverpool L25 2XT Lead Inspector Sonya Robinson Key Unannounced Inspection 22nd May 2006 11:00 Besford House DS0000035859.V287794.R01.S.doc Version 5.1 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 Besford House DS0000035859.V287794.R01.S.doc Version 5.1 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. Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Besford House Address 19 Besford Road Liverpool L25 2XT 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) 0151 498 4281 Liverpool City Council Ms Sarah Jones Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The service should at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. The matters detailed in the attached schedule of requirements must be completed in the stated timescales. A maximum of 18 younger person with a learning disability is accommodated at the care home. 27th January 2006 Date of last inspection Brief Description of the Service: Besford House is owned and run by Liverpool Social Services. The home consists of three bungalows each accommodating six residents in single bedrooms. The home provides support and personal care to 18 younger persons that have a learning disability. One of the bungalows accommodates 6 permanent residents whilst the other two provide respite care and emergency care to residents in order to give their primary carer a break. Many of the residents have been going to Besford for many years on a regular basis within the council’s policy of accessing respite care. Each bungalow has its own domestic style kitchen, laundry room, sitting room and dining room. Each bungalow has assisted baths and walk in shower and additional aids would be provided as when required. The home is situated in the Belle Vale area of Liverpool and is easily accessible by public transport and is close to shops and other community facilities, which residents are able to access. The bungalows have two members of staff and there is always one of the management team on duty. Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection visit that lasted six and half hours. During this time five service users were spoken to and three members of staff. Service user records and other records were inspected such as: fire records, staffing etc. In addition, a tour of the building was carried out. What the service does well: What has improved since the last inspection? What they could do better: Even though the registered manager requests that cover for staff vacancies and illness is provided by agency staff who are familiar with the service users the current reliance on the level of agency care staff used in the care home is a concern and must be addressed. The refurbishment plan must also be completed in a timely manner. Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Besford House DS0000035859.V287794.R01.S.doc Version 5.1 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 Besford House DS0000035859.V287794.R01.S.doc Version 5.1 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): 1,2, 3,4,5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The statement of purpose and function, and service user guide are in need of review to adequately reflect what services are provided at Besford House. Both These documents must be forwarded to CSCI upon completion. There are sound assessment procedures in place should the situation arise that a permanent placement be offered to a service user. Some progress has been made in updating service users files. This must be pursued further so records accurately reflect the assessed needs of the service user group. EVIDENCE: A Statement of Purpose is available showing the services and facilities offered at Besford House. The pictorial Statement of Purpose is in place to make the information more accessible to service users. The registered manager must now review this document and it should be forwarded to CSCI in accordance with the regulations. A review of the service user guide has commenced and the inspector was given a copy of a draft for bungalow 1. Upon completion of the service user guide for the remaining bungalows these must also be forwarded to CSCI in accordance with the regulations. There has been no permanent admission for several years. However, the service admission procedure details that service users needs would be assessed by the suitably qualified person from the care home and that the Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 9 assessment would be over a prolonged period to ensure that the service would be able to meet the service user needs. The service has had a number of emergency admissions. The Care Management Assessment is forwarded to the home promptly. However, discussion with the registered manager indicated that some emergency admissions at the care home have been for a significant time. Of the three bungalows one is used for emergencies respite, one is used for planned respite and a further bungalow is used for permanent service users. An initial Care Management Assessment was completed for service users to access the service at Besford House and a copy of the assessment is kept at the care home. The service has commenced their own daily care plans for staff reference identifying specific pertinent daily routines with regard to service user needs. This good work must be continued and built upon. During the writing of this the report the registered manger has confirmed that the home will now attend regular meetings held by social services with regard to the identifying access to the respite service. Each service user has a written contract of terms and condition and a sliding scale of fees dependent on age and type of care i.e. permanent, respite. Besford House DS0000035859.V287794.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users plans showing how needs are to be met are reviewed regularly to ensure that the appropriate care and support is provided. Appropriate risk assessments are in place to ensure that service user’s can participate in daily activities and leisure pursuits. EVIDENCE: The service user plans have begun to be reviewed since the last inspection to reflect service users current needs. Risk assessments and service user plans have also been developed for service users on respite. Besford House staff contact the service users primary carer on the day of their admission for respite. This is to obtain information regarding any changes in the service user needs and where necessary key workers amend the service user plans and risk assessment accordingly. Service users make decisions over their daily lives such as: what activities to participate in, whether to be on their own or in the group, choosing their Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 11 holiday etc. The inspector spoke with five service user’s on the day of inspection they said the following. “Its nice here”, “I like best deal or no deal” (TV programme), “ I like going to the centre” “I like my room and shopping with staff”, “ staff help me when I ask” “thank them for having me” (respite service user). The comments and responses to questions were positive about the experience of living at the home and of how staff support service users generally. The service users are supported to manage their finances with the support of staff as identified in their service user plan. A record is kept of incoming and outgoings of monies and the home is audited at regular intervals by Liverpool Social Services Finance Department. The service users are involved and made aware of changes at Besford House through the service user meeting, which is held monthly. This provides a regular opportunity to express their opinion and where necessary they are supported by the staff to do so. Service users are supported to take responsible risks by engaging and accessing various community facilities independently. The service has a missing person policy, which is implemented when a service user absence cannot be explained. The home has a policy on confidentiality of information and service users records are kept in a secure place. The registered person has devised an ‘agency staff file’ to ensure that all agency staff are aware of the service policy on confidentiality to promote the safety of service users. The recording of service users personal information has improved. This promotes service users right to privacy of information relating to them. Besford House DS0000035859.V287794.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users can engage in a good range of leisure/social activities to meet their individual needs with the support of staff as appropriate. EVIDENCE: The service users engage in a wide range of activities to develop new skills and to fulfil their social needs. All of the permanent service users attend a day centre where they engage in various activities such as: cooking, flower arrangement, etc. Where necessary staff would support service users to access activities. The service has a range of transport options available to enable service users to access community facilities such as: Dial a Ride, taxi, staff cars etc. Information about community activities is brought into the service by both service users and staff, which are displayed around the bungalows. Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 13 The home is a short walk from local shops, pubs, restaurants, churches, etc. Other parts of the city are easily accessible by public transport, which passes outside the service. One service user gestured to the inspector that the best thing about the local shops etc was ‘the fish and chips.’ Another service user was off with staff to purchase items for her bedroom and then was looking forward to having lunch out with staff. The service users have holidays, which are included in their weekly fees. Brochures are brought into the care home where service users are supported by staff to choose their holiday. Usually, the service users opt to go abroad for a holiday, sometimes as a group or on occasion individually. Several service users had just returned from Spain and several more were due to go to Malta within the next couple of days. Service users are supported to maintain and develop contact with friends and family. One of the permanent service users visits their parents for the weekend whilst others have regular visit at the care home. The service has an unrestricted visiting policy and service users are able to choose where to see their visitors. Service users rights to privacy are respected. Service users have a key to their bedroom and are supported with personal care etc. in a sensitive and appropriate manner. Service users have access to all parts of the building. Service users although not directly responsible for household tasks are encouraged to assist care workers in maintaining certain parts of their bedroom such as: tidying drawers, book shelves etc. Mealtimes at the care home are flexible to meet the service user needs. A record is to be kept of all meals provided to service users. Discussion with the registered manager indicated that service a user requiring a special diet is appropriately catered for. Besford House DS0000035859.V287794.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users health needs are being met. However, this could be improved through the employment of permanent staff to deliver service users care. EVIDENCE: Most of the service users do not require any assistance with moving and handling and require minimal support with personal care. However, where a service user on respite requires assistance with transferring suitable specialist aids are obtained from the district nurse. The registered manager informed the inspector that she has been assured by the agency that the temporary staff supplied have current moving and handling certificates. Discussion with service users, staff and entries in the service users daily records show that they choose when to go to bed and they can make decisions over their daily living activities. Currently, the service is unable to provide a key worker system to service users because of the level of agency staff used at the care home. During the writing of this report the registered manager discussed plans to implement this quickly. Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 15 The staff monitor the health needs of the service users and ensure that they receive regular health checks from the dentist, chiropodist, optician as well as a periodic review of their medication by their GP. Staff would accompany service users to outpatient appointments. Health care records are in place for service users and of the random sample inspected a couple would require updating as discussed. Service user medication is administered through a monitored dosage system and a record is kept of medication administered to service users. Currently, none of the service user administers their medication. However, a service user would be able to self-medicate following a risk assessment. An inspection of medication and records indicated that these were being given and documented appropriately. Besford House DS0000035859.V287794.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 the service. The service has various policies and procedures in place to protect service users from all forms of abuse. However, with the level of agency staff used it is difficult for the management team to assess the level of staff understanding of the policies on abuse. This presents some difficulty in being satisfied that all staff employed, including agency staff, are fully conversant with and understand their roles in relation to Adult Protection and how to respond should they need to. EVIDENCE: This outcome group remains the same as previously reported. The service has a complaints procedure, which is displayed in a prominent position. The procedure outlines how complaints would be resolved and the timescale for the completing the investigation. There has been no complaint since the last inspection. The service has various policies and procedures in place for the protection of vulnerable adults. The service uses a high percentage of agency staff to deliver care to service users. Thus, the management of the home is unable to evaluate the level of staff knowledge and understanding abuse either through the staff induction or one to one supervision, as agency staff currently do not receive individual supervision at the care home. The registered manager must ensure that the agency demonstrate that staff have an understanding and training on understanding and recognising the signs of abuse. Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 17 Besford House DS0000035859.V287794.R01.S.doc Version 5.1 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 the following standard(s): 24,25,26,27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is undergoing a refurbishment plan at the time of this inspection. The communal areas in the two bungalows used for respite care and emergency care need attention to make it more homely. Privacy and safety of service users is maintained and promoted by service users being able to lock their bedroom doors. EVIDENCE: At the time of the inspection the service has begun a refurbishment plan and the windows of all bungalows were being replaced. The bungalow used for permanent service users was found to be homely and reflects their tastes and preferences, though in parts the carpets and furniture are looking worn. The bungalows are safe, comfortable and bright and all parts the bungalow and grounds are easily accessible to service users. The grounds have benefited from having a new ramped area to increase accessibility. The communal areas could be used for a variety of purposes. However, the two respite units are Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 19 “plain”. Efforts should be made to make these bungalows more “welcoming” through pictures, bedding etc. Carpets and furniture is also worn in parts and will need to be replaced in the near future. The inspector spoke with a respite service user and their external support worker. The service user informed, “I like coming here for my holidays I can see my friends” “the sofa is comfortable, try it” (the inspector did and agreed). The support worker informed that they had always been made to feel welcome and had no concerns regarding the service. All accommodation is provided in single bedrooms and bedroom doors have suitable locks to promote service users privacy whilst maintaining their safety. Some of the permanent service users have purchased their bedroom furniture to personalise their bedroom. The bungalow has the required number of toilets and bathroom for the number of service users. These are located close to communal areas and service users bedrooms. Each bungalow has an assisted bath and a call system in service user bedroom. The domestic washing machine is in the kitchen and policies and procedures are in place to minimise the spread of infection. Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The continued reliance on agency staffing is unacceptable. The service must endeavour to rectify this unsatisfactory situation and to employ permanent staff to provide continuity of care to service users and to improve the overall quality of care provided at Besford House. EVIDENCE: Service users care is being delivered primarily by agency staff. Until recently there was only two permanent staff out of a staff group of twenty-five. This is unacceptable. Within the last couple of weeks five more staff have returned to the home after a period of secondment. The registered manager tries to ensure that the same agency staff are sent to the home to provide some level of continuity of care to service users, however this cannot be guaranteed. The staffing level is flexible to meet the changing needs of the service users as observed during the inspection. As a result of the above a number of issues now require attention. Regular staff meetings must take place, staff one to one supervision and appraisals must be documented including implementing arrangements for the supervision of agency staff who regularly work at the home. All staff files must contain the Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 21 information detailed in scheduled 2 of the Care Homes regulations 2001. The checks in place for agency workers must also be tightened to ensure that they have undertaken the appropriate checks and that they are qualified to an appropriate level to care for the service users. The registered manager must remain mindful that it is their responsibility to ensure that anyone employed to work at the home are suitable to do so and therefore they need to put in place a system that provides evidence to this effect. The inspector spoke to one permanent staff member on the day of inspection and they confirmed that were training had been offered and they were able to access it that it had been beneficial. Two of the management team are following the Post Qualifying Social Work Award. Currently, the registered manager does not provide individual supervision to agency staff. The registered manager should implement a system of monitoring the performance of agency that are working at the care home regularly. Besford House DS0000035859.V287794.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42,43 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The present level of permanent staffing does not satisfactorily support the registered manager in their attempts to implement effective change at Besford House. Consequently further attempts to develop and improve the quality of care given to service users are compromised. The authority must develop clear plans for the recruitment and retention of permanent staff in sufficient numbers to be able to meet the needs of those who use the service. Continued reliance on agency staffing at the level currently experienced potentially exposes service users to unnecessary levels of risk. EVIDENCE: The registered manager of Besford House has many years experience of working with this service user group. She has good rapport with service users Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 23 and staff. Observation and discussion with service users and staff showed that she is accessible and willing to incorporate the views of other stakeholders to improve the quality of care provided at Besford House. However the registered manager has not implemented the service quality assurance system, nor has the manager been able to demonstrate that there is continuing improvement in care provided at Besford House. In addition, the Responsible Person monthly visit reports are not being undertaken and forwarded to the Commission. The service was also found to be breach of the Care Standards Act 2000 as they had taken two service users outside the age category stipulated within the terms of their registration. These are significant shortfalls that must be addressed. The homes policies and procedures are developed by Social Services central policy unit and distributed to the various services. They are reviewed regularly to reflect changes in legislation and best practices. Service users records are maintained and kept in a secure place. The health and safety of service users and staff are promoted through regular checks and maintenance of the building and equipment used at the care home. However, the safety of service users could be improved by taking action to address the over reliance on agency staffing. The registered manager does maintain a record of all incident/accidents at the care home and the Commission is informed of all significant incidents to service users and staff. There is a current Public Liability Insurance and there are clear lines of accountability with external management. Records are kept all expenditure at the care home. Besford House DS0000035859.V287794.R01.S.doc Version 5.1 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 2 2 3 3 2 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 2 32 2 33 2 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 3 3 3 1 3 2 2 3 Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 25 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 YA1 Regulation 6 Requirement The registered manager must now review the statement of purpose and function and it must be forwarded to CSCI. The registered manager must ensure that, upon completion, the service user guides for the bungalows must be forwarded to CSCI. The registered person must ensure that all service users have a service user plan showing how their assessed needs would be met and any risk identified how they would be minimised. Commenced but remains outstanding from previous inspection The registered person must ensure that the staff working in the care home are suitably qualified, experienced and competent to meet the health and welfare of the service users. Commenced but remains outstanding from previous inspection Timescale for action 30/09/06 2 YA1 6 30/09/06 3. YA2 15 30/09/06 4. YA3 18 01/10/06 Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 26 5. YA6 15 The registered person must ensure that the service user plan is developed with the service user, where possible. It must set out how the residents’ needs are to be met. 30/09/06 6. YA18YA31 18 Commenced but remains outstanding from previous inspection The registered person must 31/07/06 ensure that the employment of any person on a temporary basis at the care home will not prevent service users from receiving such continuity of care as is reasonable to meet their needs. Commenced but remains outstanding from previous inspection The registered person must 01/10/06 ensure that staff employed in the home have qualifications suitable to the work that they are to perform, and the skills and experience for such work. Commenced but remains outstanding from previous inspection The registered person must ensure that all staff have the necessary training to promote the health and safety of the service users. This must also include agency staff. Commenced but remains outstanding from previous inspection The registered manager must ensure that choice of meals given to the service users is recorded. Commenced but remains outstanding from previous 7. YA32 19 8. YA42 13 01/10/06 9. YA17 17 31/07/06 Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 27 inspection 10. YA19 12 The registered manager must ensure that the health care records are updated for the service users identified during this visit. The home is undergoing a refurbishment plan; The registered manager must ensure that an action plan is submitted to the CSCI by the date stated, detailing what is to be done and stipulating the timescale for completion. The registered manager must also ensure that upon completion of each element of work that they notify the CSCI. The registered manager must ensure that regular staff meetings take place and that staff one to one supervision and appraisals must be documented in accordance with the regulations. The registered manager must ensure that all staff files contain the information detailed in scheduled 2 of the Care Homes Regulations 2001. The registered manager must ensure that the system checks in place for agency workers must be tightened to ensure that they have received the appropriate checks and that they are qualified to an appropriate level to care for the service users. The registered manager must implement a system of quality monitoring within this service. The Responsible Individual or their representative must visit the service at least once a month and produce a report on the conduct of the home. This must be available for inspection DS0000035859.V287794.R01.S.doc 31/07/06 11. YA24 23 31/07/06 12. YA36 18 30/09/06 13. YA34 19 31/07/06 14. YA34 19 31/07/06 15. 16. YA39 YA39 24 26 31/07/06 31/07/06 Besford House Version 5.1 Page 28 purposes. 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 YA18 Good Practice Recommendations The registered person should implement a key-worker system to meet all of the requirements of this standard. Besford House DS0000035859.V287794.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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. 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