Inspection on 27/09/06 for Brook House

This inspection was carried out on 27th September 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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brook House 13/09/07

Brook House 05/01/06

Brook House 13/09/05

Brook House 23/11/04

Brook House 20/05/04

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 Brook House 391 Padiham Road Burnley Lancashire BB12 6SZ Lead Inspector Mrs Julie Playfer Unannounced Inspection 27th September 2006 10:00 Brook House DS0000009467.V303669.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 Brook House DS0000009467.V303669.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. Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brook House Address 391 Padiham Road Burnley Lancashire BB12 6SZ 01282 413107 01282 835863 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) Mr Hurrylall Gungah Mrs Bibi Farida Gungah Care Home 10 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (1) of places Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The registered provider shall, employ a suitably qualified manager who is registered with the Commission for Social Care Inspection The LD(E) place is for a named gentleman, and the registered provdier will notify the CSCI when this person no longer resides in the home. The home must be staffed as follows: Management: 1 person on duty at all times. (Hours required per week: 105) During the day in addition to the full time manager, two carers to cover the waking hours at all times service users are in the home. During the night, an experienced carer must be employed to sleep in on the premises each night. In addition there must be, at all times another member of staff on call, in the vicinity within three minutes travelling distance. The home can accommodate a total of ten (10) service users to include up to nine (9) service users in the category of Learning Disability - LD and one Service user in the category of Learning Disability over 65 years -LD(E) 5th January 2006 4. Date of last inspection Brief Description of the Service: Brook House is a large Victorian house, situated within a short walking distance to Burnley town centre and is keeping with other houses in the neighbourhood. The home is owned by Mr and Mrs Gungah. Brook House is registered to provide personal care and accommodation for ten people with a learning disability. Accommodation is in ten single bedrooms with en suite facilities. There are two lounges, dining room and kitchen combined, bathroom, toilet and a utility room. Staff have sleeping in accommodation. There are garden areas to the front and rear with parking space. At the time of inspection the scale of charges was dependent on the level of need. The home has a statement of purpose and service users guide, which informs the current and prospective residents about the services and facilities available at the home. The registered person had also produced a brochure and CD. Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over eight and a half hours on 27th September 2006. The previous inspection took place on 5th January 2006. No additional visits have been made to the home since the last inspection. On the day of inspection there were 10 residents accommodated at the home. Information was obtained from staff records, care records and policies and procedures. The inspector undertook a partial tour of the premises and spoke to the residents, the staff on duty, the registered provider and the manager. Three residents were involved in the case tracking process. Prior to the inspection comment cards were sent to the home, which in turn were distributed to the residents and their relatives, a total of 6 cards were returned to the Commission. In addition, the registered provider completed a questionnaire about the home. What the service does well: Residents’ needs were properly assessed and reviewed at regular intervals. Professional and specialist advice was sought as necessary. Residents pursued a wide range of activities both inside and outside the home. This approach enabled residents to participate in the life of the home and gave them the opportunity to meet other people. Since the last inspection the residents had enjoyed a holiday in Cumbria, everyone spoken to said the holiday was “wonderful” and “good fun”. The residents and staff shared good relationships and there was a friendly atmosphere in the home. One resident said “I love all the staff” and another resident said she felt very supported by the manager and staff. There were arrangements in place to ensure residents were listened to and any concerns were acted upon. Staff had access to a range of training opportunities, which gave them a good understanding of their role and the needs of the residents. 86 of the staff team were qualified to NVQ level 2 or above. The residents were provided with a clean, comfortable and well maintained home and they were able to personalise their own rooms according to their own tastes and preferences. Brook House DS0000009467.V303669.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. Brook House DS0000009467.V303669.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 Brook House DS0000009467.V303669.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): 1, 2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents were provided with written information; however, some documentation required updating to provide the residents with up to date details about the services and facilities at the home. Residents’ needs were properly assessed prior to inspection. EVIDENCE: Written information was available for residents in the form of a service users guide and statement of purpose. The statement of purpose was freely available in the home for reference purposes. The service users guide had been distributed to the residents in 2005, however, the guide did not include a contract or complaints procedure and required updating in terms of the manager of the home and the registration criteria. Two residents had been admitted to the home since the last inspection. On examination of their personal files, it was evident an assessment of needs had been carried out by a social worker and staff in the home prior to admission. The assessments were detailed and addressed the residents’ personal, social, and healthcare needs. The case tracking process demonstrated that established residents had been issued with a contract, which contained details of the terms and conditions of residence. However, the residents new to the home had not been issued with this documentation. Brook House DS0000009467.V303669.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, 8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents were involved in decisions about their lives and were supported to participate in life in the home. Whilst the care plans addressed the needs of the residents, more information was required to ensure staff had detailed information about how best to meet the residents’ needs. EVIDENCE: From the case files seen, it was evident each resident had a daily living plan, based on an assessment of needs and a person centred plan. The daily living plans set out the action needed to be taken by staff to ensure needs were met. However, the information was not detailed in all files. The residents had been allocated a key worker of their choice and from discussions with residents it was apparent they had been consulted about their choice of keyworker. The care plans were written in a suitable format for both the staff and residents. However, it was noted that not all residents had signed their care plan. It was apparent that the daily living plans had been reviewed once a month. It was the practice of the home to support responsible risk taking and policies and procedures supported this approach. Risk assessments and management Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 10 strategies were available, however, these had not always been updated in line with changing needs. During conversations with residents, it was evident they were consulted both informally and formally and they were able to participate in life in the home. From the minutes seen of the resident’s meetings, it was evident a wide variety of topics were discussed and contributions had been made by the residents. The residents were supported with their financial affairs and detailed written records were maintained of all transactions. A random check of money deposited with the home for safe keeping corresponded accurately to the records. Brook House DS0000009467.V303669.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): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The residents were able to make choices about their lifestyle and were supported to develop their life skills. Social, educational and recreational activities met with the residents’ expectations. Residents were provided with a healthy diet, which they enjoyed. EVIDENCE: The individual plans and care records demonstrated that residents had opportunities to maintain and develop practical life skills. Residents were encouraged and supported to participate in the life of the home and carried out domestic tasks commensurate with their abilities and interests. These tasks included tidying bedrooms, helping in the kitchen and light domestic chores, such as dusting and vacuuming. One resident particularly enjoyed ironing. Residents engaged in activities in the local community, which included bowling, shopping, and going out for meals. Staff provided assistance with activities as necessary and had knowledge of events in the nearby area. Since the last inspection the residents had been away for a holiday in Cumbria and had been Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 12 on a barge trip. All the residents spoken to said that they “really enjoyed” their holiday and one resident said “everyone had a fantastic time”. Staffing levels were reviewed at regular intervals, which enabled residents to pursue individual leisure interests. Activities were also arranged inside the home such as dominoes, karaoke and film nights. One resident enjoyed knitting and another resident enjoyed looking at magazines both these hobbies were well supported by the staff. Since the last inspection the manager had assisted the residents to arrange various vocational courses. As such seven residents, had enrolled at college. The residents spoke enthusiastically about their courses, which included cooking, information technology, literacy and numeracy and arts and crafts. One resident had also recently gained a position as a volunteer at a local day centre for Older People. The residents were supported to maintain relationships with their families and staff provided support, where necessary, for instance one resident received staff support each weekend to visit her relative’s house. Residents could entertain their visitors in their bedroom if they wished. The residents had unrestricted access to the home and grounds. The residents were also able to use their room at any time should they wish to spend some time in private. All residents were entered onto the electoral register and exercised their vote by attending the local polling station or by entering a postal ballot form. The residents were provided with three meals a day and a range of drinks and snacks were available at all other times. Residents spoken to said, the meals were “very nice” and several people said they particularly liked the healthy options. A record of meals served was maintained, which detailed the actual food served to the residents. This record demonstrated that the residents were provided with a varied nutritious diet. The residents were encouraged and supported to purchase, prepare and serve food. Brook House DS0000009467.V303669.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health and personal care of residents was based on their individual needs. The principles of respect, dignity and privacy were put into practice. Appropriate records were in place to manage medication and arrangements were in place to ensure the staff were suitably trained. EVIDENCE: The residents’ individual care plans set out the personal support each resident required and provided details of how this support was to be delivered. However, as mentioned earlier some aspects of the daily living plans required more detail. Residents spoken to confirmed personal support was provided in private and the residents’ rights to privacy and dignity were respected. One resident confirmed staff always knocked on her door and waited to enter. The routines were flexible and residents were encouraged to have a bath or shower as frequently as they wished. The manager and staff ensured consistency and continuity for residents by the use of a key worker system. A record was also maintained of individual likes and dislikes as part of the assessment and person centred planning processes. Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 14 Healthcare needs were appropriately assessed and were included in the daily living plan. There was evidence to indicate the residents had access to NHS services and the advice of specialist services had been sought as necessary. A health action plan had also been completed with each resident to supplement the information contained in the daily living and the person centred plan. There was a set of policies and procedures in respect of handling medication in the home and appropriate records were maintained of the receipt, administration and disposal of medicines. Further to this, it was noted that the administration records incorporated photographs of the residents. However, it was evident that the medication administration record (MAR) did not include instructions for the application of creams and two staff had not signed handwritten entries on the MAR sheet. None of the residents were in receipt of controlled drugs at the time of inspection. Arrangements had been made for new staff designated to administer medication to undertake an accredited medication course. Brook House DS0000009467.V303669.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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents were able to express their concerns and views. In order to fully protect the residents the adult protection procedures required must be revised and updated. EVIDENCE: Both informal and formal arrangements were in place for the manager and staff to listen to and act on the views and concerns of residents. This was achieved during daily conversation, one to one discussion with residents and their key workers and residents’ meetings. A copy of the complaints procedure was seen during the inspection. A pictorial version of the complaints procedure had also been produced and was displayed available in the hallway. However the procedures did not include the timescales for the complaints process and were not incorporated into the service users guide. The residents were aware of the procedure and said they would speak to the staff and the manager if they had concern. The home had received two complaints since the previous inspection, which were investigated by the registered provider. The home had a copy of “No Secrets in Lancashire” and staff had access to a whistle-blowing procedure. There was also an internal vulnerable adults procedure, however, this did not fully cover the role of the Commission and the Police. The staff had access to a training video and an accompanying questionnaire. Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 16 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, 28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Brook House provided comfortable, pleasant and clean accommodation. Residents were able to personalise their bedrooms and create an individual space suitable for their needs. EVIDENCE: Brook House is a Victorian building set in its own grounds. Accommodation is provided in ten single rooms, all of which have an ensuite facility. The shared space is provided in two lounges and a dining kitchen. The home is located approximately two miles from Burnley and is situated on a main public transport route. The furnishings and fittings were domestic in character and of a good quality throughout. Since the last inspection the kitchen flooring and appliances had been replaced and the bathroom had been redecorated. The registered provider explained there was a rolling programme of maintenance and there were ongoing plans to maintain and update the fabric of the building. Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 17 Residents were able to personalise their rooms according to their own tastes and preferences. All the residents spoken to said they liked their rooms, one resident said “my room is really beautiful, I am very pleased with it”. The premises were comfortable, clean and free from offensive odours, in all areas seen. Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 18 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 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staff in the home were trained, skilled and in sufficient numbers to support the people who use the service. EVIDENCE: Staff were issued with job descriptions, which set out their roles and responsibilities. It was evident the job descriptions were linked to meeting the needs of the residents. From discussions with staff during the inspection, it was evident they had a good understanding of the residents’ needs and knew the residents well. Staff referred to the residents in respectful terms and were observed to interact in a positive and pleasant way. The staff rotas indicated that the staffing levels were regularly reviewed and additional staff were placed on duty, where necessary, to meet the needs of the residents. Since the last inspection five members of staff had left the home and new staff had been employed. The high turnover of staff was recognised by the residents and was raised as a concern by a relative on a comment card, however one Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 19 resident said “I like the team now – there have been so many left, but we really do have a good team now”. The home had a recruitment and selection procedure, however, this did not fully reflect the regulatory requirements and the implementation of the POVA (Protection of Vulnerable Adults) scheme. The files of three care workers employed in last few months were inspected. The staff had completed an application form and had attended for an interview. Relevant checks had been obtained from the Criminal Records Bureau. However, it was noted that a reference had not always been sought from previous employment, which involved contact with vulnerable adults, not all applicants had provided satisfactory explanations for gaps in their work history and only one reference had been obtained for one person prior to employment. All new employees undertook an in house induction and a LDAF induction training course. However, whilst a team training and development plan was not seen, staff had an individual training and development assessment profile. The staff team had good opportunities to attend various training courses associated with the needs of the residents. At the time of the inspection six people had completed NVQ level 2 or above, which equated to 86 of the staff team. Staff meetings were held on a regular basis. The meetings gave the opportunity to staff to share experiences and develop teamwork. The manager had established a programme to ensure staff received supervision and had an annual appraisal of their work performance. Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 20 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 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The management approach promoted positive relationships between the staff and the residents and the overall atmosphere was open and friendly. The quality assurance processes must be further developed in order to measure success in achieving the aims and objectives of the home. EVIDENCE: Since the last inspection, there had been a change of manager. The new manager was currently working towards a Registered Manager’s Award and has 10 years experience working in various residential settings. The manager explained that she intended to apply for registration with the Commission. The management approach was consultative and there were systems in place to consult both staff and residents. Relationships within the home were positive and staff spoke about the residents with respect. In turn the residents described the staff as supportive and approachable. Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 21 The home was awarded a post recognition Investors in People in 2005. Satisfaction surveys had been distributed to the residents and their relative during 2005 and the results had been collated, however an annual development plan had not been produced. At the time of the inspection there were plans to carry out a satisfaction surveys again this year. Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. However, at the time of the inspection there was not a first aider on duty at all times. Information contained in the pre-inspection questionnaire and documents seen during the visit, indicated that the gas and electrical systems were serviced at regular intervals and the home had a valid electrical safety certificate. The fire log demonstrated that regular fire alarm tests were carried out and the staff had received instructions about the fire safety procedures. To minimise the risk of scalding preset valves were fitted on every water outlet and the water temperature was tested on a regular basis. Arrangements had been made to store hazardous substances in a secure location. Health and safety checks were carried out on the environment on a monthly basis and risk assessments had been completed on safe working topics. Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 22 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 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 4 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 2 X X 2 X Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 Requirement Timescale for action 30/11/06 2. YA6 3. YA9 4. YA20 5. YA22 6. YA34 The service users guide must contain a copy of the contract and inspection report and cover the elements listed under standard 1. Following amendment the guide must be supplied to each resident. 15 Care plans must provide detailed guidance for staff on how best to meet the residents’ needs. Residents must be consulted about their care plan and asked to sign, where possible, to indicate their agreement and participation. 13 (4) Risk assessments and risk management strategies must be updated in line with changing needs. 13 (2) Detailed instructions for application of creams must be included on the medication administration record. 5, 22 The complaints procedure must cover the elements set out under Regulation 22 and be incorporated into the service users guide. 17, 18, 19 All records and checks for new schedule members of staff must be DS0000009467.V303669.R01.S.doc 30/11/06 15/11/06 27/09/06 15/11/06 27/09/06 Brook House Version 5.2 Page 24 2 7. YA37 Care Standards Act 2000 24 8. YA39 9. YA42 13 (4) collated and maintained in line with the Care Homes Regulations 2001. In line with the conditions of 15/11/06 registration the manager must apply for registration with the Commission. The registered person must 31/12/06 produce an annual development plan, which is based on a systematic cycle of planning, action and review and outcomes for the residents. There must be a qualified first 30/11/06 aider on duty at all times. 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 YA5 YA20 YA23 YA35 Good Practice Recommendations All residents should be issued with a contract detailing the terms and conditions of residence. Two staff should sign and witness any handwritten entries on the medication administration record. The adult protection procedure should cover the role of the Commission and the police. A training and development plan for the whole staff team should be available. Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Brook House DS0000009467.V303669.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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