Inspection on 23/10/07 for Boroughbridge Road (67)

This inspection was carried out on 23rd October 2007.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Boroughbridge Road (67) 22/10/08

Boroughbridge Road (67) 02/11/06

Boroughbridge Road (67) 20/03/06

Boroughbridge Road (67) 17/05/05

Boroughbridge Road (67) 13/12/04

Boroughbridge Road (67) 10/08/04

Boroughbridge Road (67) 26/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Boroughbridge Road (67) 67 Boroughbridge Road Knaresborough North Yorkshire HG5 0ND Lead Inspector David White Key Unannounced Inspection 23rd October 2007 09:00 Boroughbridge Road (67) DS0000007902.V348989.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 Boroughbridge Road (67) DS0000007902.V348989.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. Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Boroughbridge Road (67) Address 67 Boroughbridge Road Knaresborough North Yorkshire HG5 0ND 01423 869343 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) info@st-annes.org.uk St Anne’s Community Services Vacant post Care Home 3 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (1) of places Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Category LD (E) for one named service user already residing at the home. Date of last inspection Brief Description of the Service: 67 Boroughbridge Road is a care home registered by St Annes Community Services to provide personal care and accommodation to up to three adults with learning disabilities. The home consists of a two-storey, end of terrace house located on a busy road in the market town of Knaresborough. Local community facilities include shops, cafes and a post office. Each of the three bedrooms is for single accommodation, one of which has en suite facilities. These are situated on the first floor. Whilst the home does not have a passenger or stair lift, all areas are accessible to those residents currently living there. There are very well maintained garden areas to the front and side of the home with hard standing for parking to the rear. At the time of the site visit on 23rd October 2007 the fees for the home were £1196 per week and did not include costs for hairdressing, chiropody and toiletries. The home has a Statement of Purpose that explains the aims, objectives and philosophies of the home and this is available in alternative easy read and picture formats. The most recent inspection report is made available to anyone who wishes to see it. Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • Reviewing information that has been received about the home since the last inspection. Information provided by the manager who is overlooking the home on an Annual Quality Assurance Assessment questionnaire. Comment cards returned from three people who live at the home and a relative. We went to the home without telling them that we were going to visit. This report follows the visit that took place on the 23rd October 2007. The visit lasted for 5 hours with 4 hours preparation time. The visit involved speaking to all three people who live at the home and watching how staff interacted with them, gave them help and what activities were going on. Time was also spent talking to two members of care staff and the temporary manager who is overseeing the home and looking at some documents. This helped in gaining an insight into what life is like for people living in the home. The manager was available throughout the site visit and the findings were discussed with her at the end of the inspection. What the service does well: The atmosphere in the home is friendly and this helps to make people feel comfortable. Staff support people to be independent and make their own decisions so that they have control over their lives. People enjoy a range of activities that are on offer and are able to pursue their social and leisure interests. People are asked to say what they think about the help that they get and what help they would like in the future to achieve their goals. They are asked about what changes they think may be needed to make their lives better. People are involved in the planning of their meals and this helps to make sure they receive a meal that they will enjoy. Staff work hard to provide good standards of care for people so that they can feel confident that their needs will be met. Boroughbridge Road (67) DS0000007902.V348989.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. The summary of this inspection report can be made available in other formats on request. Boroughbridge Road (67) DS0000007902.V348989.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 Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People who use the service can feel confident that the home will meet their needs following assessment. EVIDENCE: The Statement of Purpose and service user guide, which provide information about the care and services on offer at the home, have both been recently updated to accurately reflect what the home provides. These are kept on display near to the entrance of the home where families and visitors can have access to it. Information is provided in easy read format using pictures to help people who have communication difficulties. The home has a pre-admission policy that outlines procedures to be followed when people are considering moving into the home. There have been no new admissions to the home for some time; however, proper pre-admission procedures have been followed in the past to make sure that only suitable people are admitted to the home. Information about the person’s care needs is collected from a number of sources including the placing authority, to support the home in their decision making about whether they have the skills and Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 9 resources to meet the person’s needs. People who are thinking about moving into the home are invited to visit the home and have a trial period before a decision is made about whether they move into the home on a permanent basis. The manager overlooking the home is currently introducing new person centred care planning documents. This means that people who are using the service are having their needs re-assessed. This will help in making sure that care and support plans are developed to meet people’s current needs. Boroughbridge Road (67) DS0000007902.V348989.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 and 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People are encouraged to make their own choices about how they live their lives and this is supported through improved care planning documentation that takes into account any risks to people. EVIDENCE: All the people who returned a survey made comments that they “like living at the home” and are “treated well by staff”. Progress has been made in improving the standard of care plans for people who use the service. Each person now has a person centred plan which places emphasis on how each person prefers to be supported in meeting his or her aims and objectives. The care plans give clear and detailed instruction on how the person’s needs would be best met. Each care plan is very personalised and includes a “Personal Profile” on each person. This includes information about Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 11 such things as how to best communicate with the person and which communication methods work and which don’t. Other information takes into account people’s choices about their preferred daily routines, their hobbies and interests and their food likes and dislikes. In one case pictorial information has been used to help one person make choices. Staff said that they found the care plans “easy to understand and follow”. The home has a key worker system so that staff can spend time with people on an individual basis. People using the service said that they meet up with their key worker regularly to talk about their care and each person’s “Personal Profile” is reviewed every six months. Prior to the review taking place the home uses the “In Control” document to seek the current views of the person about the care they receive and their wishes for the future. People said that they are able to make their own decisions and this could be observed at the time of the visit. Risk assessments have been carried out to support people to be independent and safe. Any identified risks from this are included in the risk management plans. Whilst the manager said that these are agreed with each person, there was no written evidence to show this. Daily records are detailed and up to date. There is also a communication book that is used to keep staff updated about any changes to people’s care and informal handovers take place between shifts so that information can be passed on. Boroughbridge Road (67) DS0000007902.V348989.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 and 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People are now enjoying a wider range of activities to suit their personal needs and this enables them to have more involvement in the local community. EVIDENCE: There are a variety of activities on offer for people who use the service. Some people attend day services and one person attends a local college course. Activities include horse riding, gardening, theatre visits and going to the pub. Staff said that people are able to “get out more” since the current manager took over. One person has become involved with the local church and another person has returned to a social group that they used to attend but had stopped going to. Two people have been on holiday to France earlier this year and there has been another holiday to the Lake District. The home has a lease car that is partly used for outings including a recent trip to see the Blackpool Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 13 illuminations. People who live at the home are expected to contribute a small charge towards the running of the lease car and a signed agreement of this arrangement between the home and the person or their representatives is available in their care records. All the people currently using the service can verbally communicate their needs to some extent. It is clearly and well explained in each person’s care plan about the most effective ways of communicating with the person. People can see family and friends at any time and a relative survey made comments that they are made welcome. The care records show that relatives are kept informed about people’s progress and are invited to attend meetings to discuss their relative’s care where this has been agreed. People at the home said that they “like the food”. They are involved in the planning of the menus and do the shopping with staff. Alternative foods are always available if someone chooses not to have the meal on offer. People are able to have drinks and snacks between meals if they choose to. Boroughbridge Road (67) DS0000007902.V348989.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 and 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People’s personal and healthcare needs are well met. EVIDENCE: Each person’s care plan describes how people wish to receive support. Staff could be seen providing support in private and in a way that respected people’s dignity. The manager said that arrangements for people receiving health care at the home have improved so that support is now always given in private. People using the service have a General Practitioner (GP) and access to other health care services. Each person has an annual health check and a healthmonitoring checklist is used to record appointments and outcomes from these so that staff are clear about the support that people need. People have access to specialist services such as the local Learning Disabilities Team who offer specialist advice and support when needed. The home has used a Behaviour Support Team to support them in managing one person’s behaviour. Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 15 The home uses a monitored dosage pre-packed system for medicines. All three people living at the home have their medications administered by staff. One staff member has completed accredited medication training and the other two permanent staff are currently undertaking the training. The medication records were accurate and up to date and there are systems in place for returning medications to the pharmacy. Boroughbridge Road (67) DS0000007902.V348989.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 and 23 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Clear complaints policies and procedures are in place to address people’s concerns. Measures are being put in place to make sure that staff report concerns immediately. This follows incidences when staff had failed to do this and had put people living at the home at risk of harm. EVIDENCE: The home has a detailed complaints procedure that is available in written and pictorial format. The home has not received any complaints since the previous inspection visit. However, people using the service and a relative commented that they know who they would need to speak to if they did have any concerns. There has been one adult safeguarding issue since the last inspection. The management of the home had responded appropriately to this by referring the matter to the correct authorities on receiving the information and investigations into the allegation remain ongoing. However, staff had not reported their initial concerns about the alleged incidences until some time after they took place and so proper actions could not be taken sooner to protect people. This is poor practice and the delay in reporting concerns immediately puts people at risk. Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 17 Following this incident, the manager who is currently overlooking the home has put in place measures so that staff are clear about how to respond to and report concerns when they arise. Permanent staff and agency workers have received in-house adult abuse awareness training. All staff are to have updated formal adult protection training by January 2008. Adult abuse awareness is being included as part of staff supervision and team meetings. It was encouraging that two staff seen at the time of the visit were able to say how they would respond to suspicions or allegations of abuse and could describe what they would consider signs of distress in someone who was suffering abuse. Staff are also completing “body maps” if they notice any unexplained bruising to people and all accidents or incidents are recorded. The home has a policy saying that no physical restraint is to be used in the home. Individual risk assessments and management plans are in place to minimise risks from peoples’ behaviour. There are clear systems in place for looking after people’s monies and people using the service said they could have access to their monies at any time. Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The environment is homely, clean and comfortable for people who are living there. EVIDENCE: The home has two floors with bedroom accommodation on the first floor. There are no lifts in the home and there is no ramped access to and from the premises so the home would not be suitable for people with mobility problems. Each person has their own bedroom that is personalised and decorated to suit their wishes. There is a toilet and shower area that is easily accessible and appropriate aids and adaptations are in place to assist people. The back garden has a patio area where people can sit outside if they want to. The home is clean and tidy and people said that they like living there. Since the previous inspection visit fire door guards have been fitted to a number of Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 19 doors so that they are no longer being propped open in an unsafe manner. Following discussion with the manager at the time of the visit, she is going to seek advice from the fire authority about the door leading from the office to the ground floor corridor to make sure that fire safety standards are being met. There has been some water leakage that has caused some damage to the ceiling in the dining kitchen area and some re-decoration is needed to this part of the home to make it more pleasant for people sitting in there. There are separate laundry facilities where staff attend to people’s personal clothing and bedding and procedures are followed to reduce any risk of infection. A maintenance worker attends to any necessary work and the organisation’s maintenance team carry out an annual visit to plan for future work that needs doing. Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Improvements in staff training and the support staff receive in doing their jobs helps in making sure that people are getting the care they require. Extra permanent staff are needed in order to enable people to receive more consistent care. EVIDENCE: Staffing rosters indicate that there are an adequate number of staff on duty most of the time. However, this is being achieved mainly because the three current permanent members of staff are working a lot of additional hours and through the use of agency staff. The agency staff that are being used tend to be the same workers who are familiar with the needs of the people at the home having worked with them for some time. At the time of the visit there was one member of staff on leave and two on sick so staffing resources were particularly stretched. One staff member said that they are sometimes working around 50 hours a week, and whilst they are willing to do this at the moment they did say at times they felt “tired”. Whilst the staffing shortfalls are not Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 21 preventing good standards of care to be maintained, the use of agency staff and lack of permanent staff can have an effect on staff morale particularly if it is difficult to take holidays and on the consistency of care that can be given to people. The manager said that there are currently 2.5 vacancies in the home and although the organisation has introduced more creative ways to attract more staff, as yet these have been unsuccessful. No new staff have been appointed to the home since the last inspection visit. However, in the past proper recruitments procedures have been followed and the necessary checks undertaken so that people are safeguarded from potential harm. Staff said that they receive a range of training to support them in doing their jobs. Any new staff receive the Learning Disability Award Framework (LDAF) induction and foundation training as well as other training that is specific to the needs of the people living in the home. Since the previous inspection visit staff training has improved so that all staff are up to date with their training. All the permanent members of staff have either completed or are doing a National Vocational Programme (NVQ) to develop their skills and knowledge in different aspects of care. Staff said that they receive regular supervision from the manager and feel supported in their job roles and any staffing issues are addressed through the supervision process. Staff meetings enable staff to contribute their views and opinions about the home and records from these meetings are available. Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home is well managed but the absence of a registered manager leaves the service vulnerable. This puts people at risk, as there is no one accountable for managing the service on a day-to-day basis. People who live at the home are involved in decision-making about how the home is run and proper attention is given to their health and safety. EVIDENCE: The previous manager left the home six months ago. Since then a registered manager from another nearby St Anne’s Community Services care home has been overseeing the management of the home. Initially this was seen as a temporary measure until a new manager was appointed. However this has not Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 23 happened. In the meantime the manager is sharing her time between the two homes. This means she is spending around half of her working week in each home and working additional hours to cover vacant shifts. This situation does not ensure that the home is properly managed at all times in a consistent way to meet people’s needs and this must be addressed. The temporary manager is very experienced. People living at the home and staff both said that improvements have been made since she took over. They commented that she is “very committed to improving people’s quality of life, is on the ball and has an open and honest approach”. There is now more emphasis on people getting out more and accessing educational, social and leisure facilities and care planning is now more person centred to suit people’s individual wishes. There are systems in place to seek the views of people about the running of the home. Questionnaires have recently been sent out and received from people who live at the home and regular meetings are held to enable people to have their say about how the home runs. The home has a team plan that sets out the home’s aims and objectives and there are groups that people who live at the home can attend so that they can discuss any issues with the organisation’s senior managers. The home has in the past put in place methods to seek the views of relatives and others who have contact with the home. However this has not been done for some time and would be useful so that any identified areas for improvement can be acted on. Health and safety practices help to maintain a safe environment. Fire safety is well addressed through fire safety checks and regular staff training. Since the last inspection visit the fire risk assessment has been updated and agreed with the fire officer. Health and safety certificates are up to date and this includes an electrical wiring certificate that was not available at the last inspection visit. Improvements have been made in the way that incidents are reported and recorded so that proper action can be taken promptly in response to this. Boroughbridge Road (67) DS0000007902.V348989.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 3 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 1 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 1 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 2 X LIFESTYLES Standard No Score 11 X 12 3 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 Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA23 Regulation 13 Requirement Timescale for action 23/01/08 2. YA32 3. YA37 Arrangements must be put in place to make sure that staff understand safeguarding policies and procedures that need to be followed in response to serious concerns raised, in order to protect people at the home. 18 There must be a sufficient number of permanent staff working at the home to meet the needs of people who use the service. This will help in making sure that people are receiving more consistent care. CSA A permanent manager must be Section 11 appointed and this person must make application to be registered. This is to make sure the home has a person who is responsible for the day to day running and is accountable to the Commission. 31/12/07 31/01/08 Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 26 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. 2. 3. 4. Refer to Standard YA9 YA24 YA24 YA39 Good Practice Recommendations There should be written evidence to show that outcomes from risk assessments have been agreed with the involvement of the person using the service. Arrangements should be put in place to re-decorate the part of the ceiling in the dining room that has been affected by water leakage. Advice should be sought from the fire authority about the door leading from the office to the downstairs corridor to make sure that it meets fire safety standards. Better arrangements should be put in place to seek the views and opinions of relatives and other people who have contact with the home. This will enable more people to have a say in what the home is doing well and in identifying any areas for improvement. Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Boroughbridge Road (67) DS0000007902.V348989.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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